Nokea
The nurse is reinforcing teaching of proper technique for colostomy irrigation for the home health client. Which client action indicates that further instruction is required?
- A. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place
- B. Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing
- C. Hangs the irrigation container on a hook at the level of the shoulder approximately 18-24 inches above the stoma
- D. Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs
Correct Answer: A
Rationale: Using an enema set is incorrect; a cone-tipped irrigator is required for safe colostomy irrigation. Water volume , height , and clamping are correct.
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A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest
- A. during the night shift when staffing is limited
- B. when the client's mood improves with an increase in energy level
- C. at the time of the client's greatest despair
- D. after a visit from the client's estranged partner
Correct Answer: B
Rationale: Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.
The nurse is reinforcing teaching about breastfeeding to a postpartum client. Which statement by the client indicates a correct understanding of teaching?
- A. I will feed my baby for 5-10 minutes on each breast.
- B. I will hold my baby on their back with the head turned toward my breast.
- C. If I need to reposition my baby's latch, I will use my finger to break the suction first.
- D. The baby's mouth should grasp only the nipple, not the areola.
Correct Answer: C
Rationale: Breaking suction with a finger prevents nipple trauma. Short feeding times , lying on back , and nipple-only latch are incorrect.
A client is receiving Vincristine (Marqibo). The client should be taught that the medication can:
- A. Cause diarrhea
- B. Change the color of her urine
- C. Cause mental confusion
- D. Cause changes in taste
Correct Answer: C
Rationale: Vincristine can cause neurotoxicity, including mental confusion. Diarrhea, urine color changes, and taste alterations are less common.
The nurse is assisting in caring for a client who had a transsphenoidal hypophysectomy 48 hours ago and has developed diabetes insipidus. Which of the following prescriptions should the nurse clarify?
- A. Administer desmopressin
- B. Check the client's urine osmolarity daily
- C. Obtain a blood specimen to check the serum sodium level
- D. Place the client in Trendelenburg position
Correct Answer: D
Rationale: Desmopressin treats diabetes insipidus by replacing vasopressin. Checking urine osmolarity and serum sodium monitors the condition. Trendelenburg position is inappropriate as it may increase intracranial pressure post-hypophysectomy.
An adult postoperative client vomits, and his abdominal wound eviscerates. What is the best initial action for the nurse to take?
- A. Cover the exposed coils of intestine with sterile moist towels or dressings
- B. Pack the intestines back into the abdominal cavity
- C. Irrigate the exposed coils of intestines with sterile water
- D. Take the client's vital signs
Correct Answer: A
Rationale: Covering exposed intestines with sterile moist dressings prevents infection and drying of tissue, stabilizing the client until surgical intervention. Packing intestines risks contamination, irrigation is inappropriate, and vital signs are secondary to immediate protection.