Nokea
The nurse observes a newly hired nurse care for a client with a colostomy. Which action by the newly hired nurse requires follow-up? Select all that apply.
- A. Empties the pouch when it is one-third to one-half full.
- B. Washes the surrounding skin with moisturizing soap.
- C. Indicates that the reddish appearance of the stoma as normal.
- D. Applies sterile gloves prior to changing the device.
- E. Applies isopropyl alcohol to the surrounding skin to promote adherence with the wafer.
Correct Answer: B,D,E
Rationale: Using moisturizing soap (B) can interfere with appliance adhesion, sterile gloves (D) are unnecessary as clean gloves suffice, and isopropyl alcohol (E) can irritate the skin. Emptying the pouch appropriately (A) and recognizing a normal stoma (C) are correct.
You may also like to solve these questions
The nurse is assessing a client who has appendicitis. Which of the following would be an expected finding? Select all that apply.
- A. Leukocytosis
- B. Melena
- C. Fever
- D. Nausea and Vomiting
- E. Anorexia
Correct Answer: A,C,D,E
Rationale: Appendicitis commonly presents with leukocytosis (A) due to infection, fever (C) from inflammation, nausea and vomiting (D), and anorexia (E) due to gastrointestinal irritation. Melena (B) is not typically associated with appendicitis.
The nurse is caring for a client who is having a liver biopsy. Which positioning should the nurse place the client in immediately following the procedure?
- A. Supine
- B. Right lateral
- C. Sitting position with legs dangling off the edge of the bed
- D. Left lateral
Correct Answer: B
Rationale: Right lateral positioning (B) applies pressure to the biopsy site, minimizing bleeding risk post-liver biopsy.
The nurse cares for a client who had a liver transplant 48 hours ago. It would be a priority for the nurse to notify the healthcare provider (HCP) if the client has
- A. An increase in oral temperature from 97.8°F (36.6°C) to 98.6°F (37°C).
- B. Rising aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels.
- C. A moderate amount of serosanguinous drainage to the incision.
- D. Nausea following the administration of oral pain medication.
Correct Answer: B
Rationale: Rising AST and ALT levels (B) indicate possible liver graft dysfunction or rejection, a critical finding requiring immediate HCP notification post-transplant.
The nurse is performing teaching for a client scheduled for gastric bypass surgery. Which client statement requires follow-up by the nurse?
- A. Once I am home, I can advance my diet as tolerated.
- B. I will have to take a multivitamin after this surgery.
- C. I will be encouraged to perform leg exercises while I am in bed.
- D. My weight may increase if I do not change my eating habits.
Correct Answer: A
Rationale: Advancing the diet as tolerated (A) is incorrect; gastric bypass patients follow a strict, staged diet progression to prevent complications. Other statements (B, C, D) are accurate.
The nurse assesses a client receiving total parenteral nutrition (TPN) and fat emulsions. The nurse observes that the fat emulsion infusion is one hour behind schedule. The nurse should take which action?
- A. Adjust the infusion rate to make up the difference over the next hour, then revert the infusion rate back to the prescribed rate.
- B. Increase the infusion rate to ensure that the infusion finishes at the correct time.
- C. Ensure the fat emulsion infusion rate is infusing at the prescribed rate and maintain the rate at the prescribed rate.
- D. Stop the infusion and inform the primary health care provider (PHCP).
Correct Answer: C
Rationale: Fat emulsions must be infused at a steady, prescribed rate to prevent complications like fat overload syndrome. Adjusting or increasing the rate can be dangerous, and stopping the infusion is unnecessary unless there’s a specific issue.