Nokea
The nurse is teaching the client with an ileal conduit regarding skin care to prevent excoriation. In addition to applying a well-fitted collection bag the client should be told to empty the collection bag:
- A. Every hour
- B. When it is half full
- C. Once daily
- D. When it is one-third full
Correct Answer: D
Rationale: The client should be told to empty the collection bag when it is one-third full. Answer A isn't necessary or feasible, so it is incorrect. Waiting until the collection bag is half full or more as suggested in answers B and C increases the likelihood of skin exposure to urine thereby contributing to excoriation.
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An 87-year-old woman is admitted to the acute care hospital for heart failure. The nurse asks about the client's signs and symptoms and obtains vital signs. Considering the client's age, what additional question is most important for the nurse to ask?
- A. How do you manage your bowels?
- B. When was your last menstrual period?
- C. What are your favorite foods?
- D. When was your last tetanus shot?
Correct Answer: D
Rationale: Elderly patients are at risk for tetanus due to waning immunity; assessing vaccination status is critical for infection prevention.
Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)?
- A. Neuro malignant syndrome
- B. Acute extrapyramidal syndrome
- C. Glaucoma, prostatic hypertrophy
- D. Parkinson's disease, atypical tremors
Correct Answer: C
Rationale: Glaucoma, prostatic hypertrophy. These are contraindications to benztropine due to its anticholinergic effects.
If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
- A. Obtain emergency equipment
- B. Assess heart rate, rhythm and all pulses
- C. Apply pressure to the vessel insertion site
- D. Use cold packs at the exit incision site
Correct Answer: C
Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site to prevent bleeding and complications.
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
- A. Check pedal pulses.
- B. Check legs for pitting edema.
- C. Upper extremity neuro checks.
- D. Auscultate lung sounds.
- E. Observe respirations.
- F. Observe for gait disturbances.
Correct Answer: B,D,E
Rationale: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
A 22-year-old woman comes to the hospital at term in the early stages of labor. A diagnosis of complete placenta previa is made.
It would be MOST important for the nurse to take which of the following actions?
- A. Start an IV of terbutaline (Brethine) and monitor the patient's vital signs closely.
- B. Prepare the patient for an immediate cesarean section.
- C. Maintain the patient on bedrest until spontaneous vaginal delivery is achieved.
- D. Monitor the patient's length and duration of contractions.
Correct Answer: B
Rationale: Strategy: Answers are both assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, Brethine used to delay delivery in preterm labor (2) correct-implementation, cannot deliver vaginally (3) implementation, cannot deliver vaginally (4) assessment, cannot deliver vaginally, cesarean section must be performed