Nokea
The nurse is planning care for a client who had surgery for an ileal conduit two days ago. It is MOST important for the nurse to take which of the following actions?
- A. Remove the appliance regularly and clean the skin with antiseptic solution.
- B. Apply a close-fitting drainage bag to the stoma.
- C. Massage the skin around the stoma with an emollient.
- D. Expose the area around the stoma to air twice a day.
Correct Answer: B
Rationale: A close-fitting drainage bag prevents urine leakage, protecting skin integrity post-ileal conduit. Options A, C, and D risk skin irritation or bag adhesion issues.
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An upset client says to the nurse, 'Where did you learn to be a nurse? You don't know anything.' How should the nurse respond?
- A. I'm sorry you feel that way.'
- B. I went to a fine nursing school.'
- C. You sound upset.'
- D. Please don't speak to me that way.'
Correct Answer: C
Rationale: Reflecting the client's emotions ('You sound upset') opens therapeutic dialogue, addressing feelings without defensiveness. Other responses escalate or dismiss.
The nurse is caring for a client receiving warfarin (Coumadin) 5 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I eat a salad with spinach every day.
- B. I take ibuprofen for my headaches.
- C. I drink a glass of red wine with dinner.
- D. I walk for 30 minutes every morning.
Correct Answer: B
Rationale: Ibuprofen, an NSAID, increases bleeding risk when taken with warfarin, a significant concern due to potential for hemorrhage. Options A, C, and D are less critical: spinach (vitamin K) may require dose adjustment, moderate wine is generally safe, and walking is beneficial.
The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM.
- A. What is the most appropriate action for a saturated dressing with dark, greenish-yellow drainage two hours after T-tube removal?
- B. Remove the dressing and replace it with a more absorbent dressing.
- C. Collect a culture and sensitivity specimen of the drainage.
- D. Observe the wound for dehiscence.
- E. Reinforce the dressing with an 8x10 dressing.
Correct Answer: A
Rationale: Dark, greenish-yellow drainage is expected bile after T-tube removal. Replacing the saturated dressing with a more absorbent one keeps the site clean and dry, preventing infection. Cultures are unnecessary without infection signs, dehiscence is unlikely, and reinforcing risks infection.
In planning discharge teaching for a client after a lumbar laminectomy, the nurse would instruct the client to exercise regularly to strengthen which muscles?
- A. Anal sphincter.
- B. Abdominal.
- C. Trapezius.
- D. Rectus femoris.
Correct Answer: B
Rationale: strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine
An adult is being discharged from the emergency room with instructions to apply a cold pack to his sprained ankle. The client asks why it is necessary to use a cold pack. The nurse replies that the cold pack will do which of the following?
- A. Keep the sprain from becoming a fracture
- B. Prevent bruising and ecchymosis from occurring
- C. Keep the client from developing a fever
- D. Help reduce swelling and pain
Correct Answer: D
Rationale: Cold packs reduce swelling and pain by constricting blood vessels and numbing the area, aiding sprain recovery. They don't prevent fractures, bruising, or fever.