Nokea
What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
You may also like to solve these questions
A client with diverticulosis asks about preventing flare-ups. Which recommendation should the nurse provide?
- A. Take a daily laxative to ensure regularity.
- B. Avoid nuts and seeds in the diet.
- C. Increase intake of red meat.
- D. Limit physical activity to reduce strain.
Correct Answer: B
Rationale: Avoiding nuts and seeds may reduce the risk of diverticulitis flare-ups by preventing irritation of diverticula, though evidence is mixed. Daily laxatives are not recommended, red meat is not restricted, and limiting activity is unnecessary. CN: Health promotion and maintenance; CL: Synthesize
A car accident involves four vehicles on a remote interstate. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter to the nearest hospital?
- A. 10-year-old with a simple fracture of the femur who is crying and cannot find his parents.
- B. Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is unconscious.
- C. Middle-aged man with severe asthma and a heart rate of 120 bpm who is having difficulty breathing.
- D. 70-year-old man with a severe headache who is conscious.
Correct Answer: B
Rationale: The unconscious woman with signs of shock (cold, clammy skin, tachycardia) is in critical condition and requires immediate transport to stabilize her condition.
A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedure tasks? Select all that apply.
- A. Administer all ordered oral medications.
- B. Check for iodine sensitivity.
- C. Verify that written consent has been obtained.
- D. Withhold food and oral fluids before the procedure.
- E. Insert a urinary drainage catheter.
Correct Answer: B,C,D
Rationale: Checking iodine sensitivity (B), verifying consent (C), and withholding food/fluids (D) are standard pre-catheterization tasks to ensure safety and preparedness.
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: Fluid sequestration into the retroperitoneal space (B) causes significant hypovolemia in pancreatitis, complicating shock management. Intestinal hemorrhage (A), infection (C), and cardiac output (D) are secondary or less common contributors.
A male client with a head injury regains consciousness and the normal loss. Which of the following nursing statements is most appropriate as the client awakens?
- A. I'll get your family.
- B. Can you tell me your name and where you live?
- C. I'll bet you're a little confused right now.
- D. You are in the hospital. You were in an accident and unconscious.
Correct Answer: D
Rationale: Providing clear, concise orientation information is most appropriate for a client regaining consciousness to reduce confusion and anxiety. Calling family, asking for personal details, or assuming confusion may overwhelm or distress the client.