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The nurse is caring for patients with ostomies.In which ostomy location will the nurse expect very liquid stool to be present?
- A. Sigmoid
- B. Transverse
- C. Ascending
- D. Descending
Correct Answer: C
Rationale: The correct answer is C: Ascending. Stool consistency varies based on the location of the ostomy. The ascending colon is responsible for absorbing water from stool, so an ostomy in this location will have very liquid stool. Sigmoid, transverse, and descending colons are responsible for further solidifying stool, so ostomies in those locations would not typically have very liquid stool.
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The nurse learns about cultural issues involvedin the patient’s health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating?
- A. Marginalized groups
- B. Health care disparity
- C. Transcultural nursing
- D. Culturally congruent care
Correct Answer: D
Rationale: The correct answer is D: Culturally congruent care. This concept refers to providing care that aligns with the patient's cultural beliefs and practices. By learning about cultural issues and enabling patients to receive care that is meaningful and supportive within their cultural context, the nurse is demonstrating culturally congruent care.
A: Marginalized groups - This refers to groups in society who are disadvantaged and face discrimination. While understanding cultural issues may be important when caring for marginalized groups, it is not the main concept demonstrated in this scenario.
B: Health care disparity - This refers to differences in access to healthcare and health outcomes among different populations. While cultural competence can help address healthcare disparities, it is not the concept being demonstrated here.
C: Transcultural nursing - This refers to providing care across different cultures. While related, it does not specifically address the nurse's role in understanding and enabling culturally appropriate care for individual patients and families.
A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection- related death in oncology patients?
- A. Encourage several small meals daily.
- B. Provide skin care to maintain skin integrity.
- C. Assist the patient with hygiene, as needed.
- D. Assess the integrity of the patients oral mucosa regularly.
Correct Answer: D
Rationale: The correct answer is D: Assess the integrity of the patients oral mucosa regularly. Myelosuppression leads to decreased white blood cells, increasing infection risk. The oral mucosa can be a common site for infections. Regular assessment helps in early detection and intervention.
A: Encouraging small meals does not directly address infection risk in myelosuppressed patients.
B: Providing skin care is important for overall patient care but does not directly address the leading cause of infection-related death.
C: Assisting with hygiene is important but does not specifically target the leading cause of infection-related death in oncology patients.
Which nursing actions will the nurse implementwhen collecting a urine specimen from a patient? (Select all that apply.)
- A. Growing urine cultures for up to 12 hours
- B. Labeling all specimens with date, time, and initials
- C. Allowing the patient adequate time and privacy to void
- D. Wearing gown, gloves, and mask for all specimen handling
Correct Answer: B
Rationale: The correct answer is B: Labeling all specimens with date, time, and initials. This is important for proper identification and tracking of the specimen.
- Choice A is incorrect because urine cultures typically take longer than 12 hours to grow.
- Choice C is incorrect as privacy is important but not a specific action related to urine specimen collection.
- Choice D is incorrect as wearing gown, gloves, and mask may not be necessary for routine urine specimen collection, unless there are specific precautions needed.
You are caring for a patient who has been diagnosed with genital herpes. When preparing a teaching plan for this patient, what general guidelines should be taught?
- A. Thorough handwashing is essential.
- B. Sun bathing assists in eradicating the virus.
- C. Lesions should be massaged with ointment.
- D. Self-infection cannot occur from touching lesions during a breakout.
Correct Answer: A
Rationale: The correct answer is A because thorough handwashing is essential in preventing the spread of genital herpes. This helps reduce the risk of transmission to other parts of the body or to other individuals. Sunbathing (B) does not eradicate the virus and can actually worsen symptoms. Massaging lesions with ointment (C) can aggravate the sores and lead to further infection. Self-infection (D) can occur from touching lesions during a breakout due to the highly contagious nature of the virus. Therefore, teaching the patient about thorough handwashing is crucial in managing and preventing the spread of genital herpes.
A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family?
- A. The patient should not be in contact with the baby after delivery.
- B. The patients treatment poses no risk to his daughter or her infant.
- C. The patients brachytherapy may be contraindicated for safety reasons.
- D. The patient should avoid close contact with his daughter for 2 months.
Correct Answer: B
Rationale: The correct answer is B because brachytherapy does not pose a risk to the patient's daughter or her unborn child. Brachytherapy involves placing radioactive sources inside or near the tumor, which does not make the patient radioactive. The radiation does not travel far and does not pose a risk to others. Therefore, the daughter and her infant are safe from any radiation exposure. Choices A, C, and D are incorrect because there is no need for the patient to avoid contact with the baby after delivery, the brachytherapy is not contraindicated for safety reasons, and there is no requirement for the patient to avoid close contact with his daughter for 2 months.