Nokea
The nurse should teach the client with an ileal conduit to prevent urine leakage when changing the appliance by using which of the following procedures?
- A. Insert a gauze wick into the stoma.
- B. Close the opening temporarily with a cellophane seal.
- C. Suction the stoma before changing the appliance.
- D. Avoid oral fluids for several hours before changing the appliance.
Correct Answer: A
Rationale: Inserting a gauze wick into the stoma temporarily absorbs urine, preventing leakage during appliance changes, ensuring a dry field for secure adhesion.
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A common abnormal laboratory result associated with the development of peripheral vascular disease (PVD) is:
- A. High serum calcium level
- B. High serum lipid levels
- C. Low serum lipid levels
- D. Low serum calcium level
Correct Answer: B
Rationale: High serum lipid levels, particularly elevated low-density lipoprotein (LDL) cholesterol, are a major risk factor for atherosclerosis, which underlies PVD. Lipid accumulation in arterial walls leads to plaque formation, narrowing vessels and reducing blood flow. Calcium levels are not directly associated with PVD, and low lipid levels are not a risk factor.
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
- A. Preventing constipation.
- B. Administering lactulose (Cephulac).
- C. Monitoring coordination while walking.
- D. Checking the pupil reaction.
- E. Increasing food and fluids high in carbohydrate.
- F. Encouraging physical activity.
Correct Answer: A,B
Rationale: Preventing constipation (A) and administering lactulose (B) reduce ammonia levels, key in managing hepatic encephalopathy. Coordination (C) and pupil reaction (D) are unrelated. High carbohydrates (E) and physical activity (F) are not primary goals.
The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client says that she will decrease her intake of which of the following foods?
- A. Fats.
- B. High-sodium foods.
- C. Carbohydrates.
- D. High-calcium foods.
Correct Answer: A
Rationale: Decreasing fat intake is key to managing GERD, as fatty foods relax the lower esophageal sphincter and delay gastric emptying, worsening reflux.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
- A. Cholesterol level.
- B. Pupil size and pupillary response.
- C. Bowel sounds.
- D. Echocardiogram. SUPPRESSED
Correct Answer: B
Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.
After a subtotal gastrectomy, care of the client's nasogastric (NG) tube and drainage system should include which of the following nursing interventions?
- A. Irrigate the tube with 30 mL of sterile water every hour, if needed.
- B. Reposition the tube if it is not draining well.
- C. Monitor the client for nausea, vomiting, and abdominal distention.
- D. Turn the machine to high suction if the drainage is sluggish on low suction.
Correct Answer: C
Rationale: Monitoring for nausea, vomiting, and abdominal distention is essential to detect complications such as obstruction or ileus. Routine irrigation, repositioning, or increasing suction without medical orders is unsafe.