Nokea
What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
- A. Presence of blood in stools
- B. Oozing liquid stool
- C. Continuous climbing flatulence
- D. Absence of bowel movements
Correct Answer: B
Rationale: Oozing liquid stool. When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea.
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A female client talks to the nurse in the provider's office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?
- A. I am the one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occur more frequently.'
- B. My fibroids are noncancerous tumors that grow slowly.'
- C. My associated problems I have had are pelvic pressure and pain, urinary incontinence, and constipation.'
- D. Fibroids that cause no problems still need to be taken out.'
Correct Answer: D
Rationale: Fibroids that cause no findings may require only 'watchful waiting' with no treatment. Only when the client's findings become disturbing to them would surgical interventions be considered.
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
- A. apply suction for no more than 10 seconds
- B. maintain sterile technique
- C. lubricate 3 to 4 inches of the catheter tip
- D. withdraw catheter in a circular motion
Correct Answer: A
Rationale: Applying suction for more than 10 seconds may result in hypoxia. Although options B, C, and D are important during suctioning a tracheostomy, hypoxia results from actions that decrease the oxygen supply.
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
- A. A 79 year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. An incontinent client who has had 3 diarrhea stools
- D. An 80 year-old ambulatory diabetic client
Correct Answer: A
Rationale: A 79 year-old malnourished client on bed rest. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.
The nurse is caring for the client with DM who has an open wound on the left heel. Which assessment findings should the nurse associate with a wound infection? Select all that apply.
- A. Oral temperature 100.6°F (38°C)
- B. Heel feels warm when touched
- C. Yellow and purulent drainage
- D. Reduced sensation in the left foot
- E. Elevated white blood cell count
Correct Answer: A,B,C,E
Rationale: A: Fever indicates possible infection. B: Warmth suggests inflammation or infection. C: Purulent drainage is a sign of infection. E: Elevated WBC count indicates an immune response to infection. D: Reduced sensation is related to neuropathy, not infection.
A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?
- A. Chest pain
- B. Pallor
- C. Inspiratory crackles
- D. Heart murmur
Correct Answer: C
Rationale: Inspiratory crackles. In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of inefficient cardiac pumping.