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The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage?
- A. Place a 4x4 wick in the stoma opening
- B. Apply a layer of zinc oxide ointment to the perimeter of the stoma
- C. Cut the bag opening to the measurement of the stoma size
- D. Administer a PRN antidiarrheal agent
Correct Answer: C
Rationale: To prevent leakage of stool under the disposable ostomy bag, the nurse should cut the bag opening to the measurement of the stoma size. This action ensures a proper fit, which is crucial in preventing leaks that can lead to skin irritation and compromise stoma care. Placing a 4x4 wick in the stoma opening or applying zinc oxide ointment may not address the issue of leakage effectively. Administering a PRN antidiarrheal agent is not directly related to preventing leakage caused by an ill-fitting ostomy bag.
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A client with a chronic illness expresses frustration over their condition. What is the nurse's best response to support the client?
- A. Encourage joining a support group for emotional support
- B. Discuss the possibility of a cure in the future
- C. Suggest focusing on positive aspects of their life
- D. Validate their feelings and listen to their concerns
Correct Answer: D
Rationale: The best response for the nurse to support a client expressing frustration over their chronic illness is to validate their feelings and listen to their concerns (Option D). This approach helps acknowledge the client's emotions, demonstrates empathy, and establishes a therapeutic relationship. By validating the client's feelings and actively listening to their concerns, the nurse offers a supportive environment for the client to express their frustrations. Choices A, B, and C are not the best responses in this situation. While joining a support group, discussing a cure, or focusing on positive aspects can be beneficial interventions, the immediate priority is to validate the client's feelings and provide a space for them to express their frustrations.
The client with high blood pressure is being taught by the nurse to avoid adding salt during cooking. What effect does sodium have on blood pressure?
- A. It decreases the viscosity of blood
- B. It leads to increased fluid retention
- C. It causes vasoconstriction of the blood vessels
- D. It enhances the excretion of potassium
Correct Answer: C
Rationale: The correct answer is C: 'It causes vasoconstriction of the blood vessels.' Sodium can lead to vasoconstriction, which narrows the blood vessels, increasing resistance to blood flow and subsequently raising blood pressure. Choices A, B, and D are incorrect. Sodium does not decrease blood viscosity, but it can lead to fluid retention, which increases blood volume and pressure. It does not enhance the excretion of potassium; instead, high sodium intake can lead to potassium excretion by the kidneys.
The nurse is monitoring a client with an IV infusion in the left antecubital fossa. The site is warm, red, and without swelling. What conclusion should the nurse draw from these findings?
- A. The IV fluids are infusing into the subcutaneous tissues
- B. The infusion pump is functioning properly
- C. The insertion date should be verified and the IV discontinued
- D. The site is inflamed and should be reported
Correct Answer: B
Rationale: The correct answer is B. Warmth and redness at the IV site without swelling indicate a localized reaction, which is common and does not necessarily indicate infiltration of IV fluids into the subcutaneous tissues. The absence of swelling suggests that the IV is correctly placed. Therefore, the nurse should conclude that the infusion pump is functioning properly. Choice A is incorrect as warmth and redness alone do not indicate subcutaneous infiltration. Choice C is incorrect as discontinuing the IV solely based on warmth and redness without swelling is not necessary. Choice D is incorrect as the absence of swelling signifies a localized reaction rather than inflammation requiring immediate reporting.
The nurse is assessing a client with congestive heart failure who is receiving furosemide (Lasix). Which laboratory value should the nurse monitor closely?
- A. Sodium level
- B. Potassium level
- C. Calcium level
- D. Chloride level
Correct Answer: B
Rationale: The correct answer is B: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring the potassium level is crucial to prevent complications such as cardiac arrhythmias. Sodium level (choice A) is not typically affected by furosemide. Calcium level (choice C) and chloride level (choice D) are also not the primary focus of monitoring when a client is on furosemide for heart failure.
The nurse is caring for a client postoperatively following a thyroidectomy. Which assessment finding should be reported to the healthcare provider immediately?
- A. Hoarseness of the voice.
- B. Slight swelling at the incision site.
- C. Tingling around the mouth.
- D. Mild fever.
Correct Answer: C
Rationale: Tingling around the mouth should be reported to the healthcare provider immediately as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common postoperatively due to surgical manipulation, slight swelling at the incision site is a normal response, and a mild fever can be expected after surgery. However, tingling around the mouth suggests a potential calcium imbalance, which requires prompt attention to prevent serious complications.