Nokea
The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
- A. If I limit my fluid intake, I will not have to empty my ostomy pouch as often.
- B. I can place an aspirin tablet in my pouch to decrease odor.
- C. I can usually keep my ostomy pouch on for 3 to 7 days before changing it.
- D. I must use a skin barrier to protect my skin from urine.
- E. I should supply my ostomy pouch of urine when it is full.
Correct Answer: C,D
Rationale: Keeping the pouch on for 3-7 days and using a skin barrier are correct practices. Limiting fluids increases infection risk, aspirin is unsafe, and the last option is unclear but likely a typo for emptying when full, which is correct but not listed as such.
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A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation?
- A. Tell the client firmly that she needs assistance and help her with her care.
- B. Praise the client for her desire to be independent and give her extra time and encouragement.
- C. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help.
- D. Suggest to the client that if she insists on self-care, she should at least modify her routine.
Correct Answer: B
Rationale: Praising independence and providing extra time respects the client's autonomy while supporting her efforts. Forcing help, labeling her unrealistic, or suggesting modifications may undermine her dignity.
The nurse should caution sexually active female clients taking isoniazid (INH) that the drug has which of the following effects?
- A. Increases the risk of vaginal infection.
- B. Has mutagenic effects on ova.
- C. Decreases the effectiveness of hormonal contraceptives.
- D. Inhibits ovulation.
Correct Answer: C
Rationale: Isoniazid induces liver enzymes, potentially reducing the effectiveness of hormonal contraceptives. It does not increase vaginal infection risk, affect ova, or inhibit ovulation.
When performing postural drainage, which of the following factors promotes the movement of secretions from the lower to the upper respiratory tract?
- A. Friction between the cilia.
- B. E. Force of gravity.
- C. Sweeping motion of cilia.
- D. Involuntary muscle contractions.
Correct Answer: B
Rationale: The force of gravity in postural drainage positions the body to allow secretions to drain from lower to upper airways. Cilia and muscle contractions aid clearance but are not the primary mechanism.
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip for afterload reduction per physician orders. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. Which of the following has the highest priority?
- A. Assess the 12-lead EKG.
- B. Assess the blood pressure.
- C. Assess the lung sounds.
- D. Assess the urine output.
Correct Answer: B
Rationale: A sudden drop in pulmonary pressures may indicate hypotension from nitroprusside. Assessing blood pressure is the priority to ensure adequate perfusion.
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity based on lab and clinical findings (e.g., age, white blood cell count, glucose). Vital signs (B) and urine output (C) are important but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis.