Nokea
What potentially life-threatening complication can the client have if corticosteroids are abruptly withdrawn or the client has significant stress due to the impending surgical procedure?
- A. Cushing's disease
- B. Myxedema coma
- C. Thyroid storm
- D. Adrenal crisis
Correct Answer: D
Rationale: Adrenal crisis is potentially life-threatening and can result from the abrupt withdrawal of corticosteroids or significant stress after the client has been treated with corticosteroids. Cushing's disease is a condition caused by increased levels of cortisol. Myxedema coma is a result of dangerously decreased levels of thyroid hormone. Thyroid storm is a life-threatening condition caused by excessive thyroid hormone.
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The nurse is instructing a client with an ileostomy on appliance and changing it. What statement made by the client demonstrates the client understands using a new appliance for the first time?
- A. I will patch test it first on nonirritated skin at the inner side of my forearm.'
- B. I can expect the new appliance to sting or itch for the first 24 hours.'
- C. When changing the appliance and faceplate, I should scrub vigorously to remove all debris.'
- D. I should change the faceplate every 8 hours.'
Correct Answer: A
Rationale: When using a new adhesive product, the client should patch test it first on nonirritated skin at the inner aspect of the forearm. The most common causes of discomfort are reactions to the adhesive or solvent used to remove it or irritation from leaking fecal drainage. In such cases, the client may experience stinging, tingling, or itching immediately after an appliance change. If a sensation is prolonged or intensified, the client should remove the appliance regardless of whether it has been on for 1 hour or several days. The client should avoid rubbing, which may further irritate skin. If the faceplate is changed too frequently, skin around the stoma may become raw and excoriated secondary to removal of protective layers of epithelium with the faceplate.
The nurse is preparing to irrigate a client's single-barrel colostomy after surgery. The nurse would expect an order from the healthcare provider to irrigate the colostomy on what day after surgery?
- A. Fourth or fifth postoperative day
- B. The day after surgery
- C. The seventh postoperative day
- D. The colostomy should be irrigated immediately postop
Correct Answer: A
Rationale: Colostomy irrigation begins on the fourth or fifth postoperative day. Standard irrigation is a scheduled irrigation, using 500 to 1500 mL of tepid water.
A client has been discharged from the acute care facility with an ileostomy. The client comes to the clinic for a follow-up visit and informs the nurse that the wound has been draining and they are having abdominal pain and running a fever. What does the nurse suspect is occurring with the client?
- A. The client is having an allergic reaction to the appliance.
- B. The client has developed anemia from blood loss.
- C. The client has developed a wound infection.
- D. The client is not emptying the pouch correctly.
Correct Answer: C
Rationale: Signs of wound infection are wound drainage, abdominal pain, and elevated temperature. These symptoms do not indicate an allergic reaction, anemia, or not emptying the pouch correctly.
A client with an ileostomy tells the nurse that he is having a lot of problems with the formation of gas. What can the nurse tell the client to help her with this a common issue?
- A. Eat slowly and chew food well with mouth closed.
- B. Restrict fluids.
- C. Administer an enema to clear out the stool.
- D. Dilate the stoma.
Correct Answer: A
Rationale: The client should eat slowly and chew food well with the mouth closed to help lessen the development of gas. Restricting oral intake should only be done with medical supervision and will not help with gas reduction. Enemas should not be administered. The stoma is only dilated when the stool volume decreases.
The nurse is providing ostomy care to the client with an ileostomy. What can the nurse use to promote adhesion of the ostomy appliance?
- A. Adhesive glue
- B. Tincture of Benzoin
- C. Vaseline
- D. Karaya paste
Correct Answer: D
Rationale: Karaya paste, which becomes gelatinous when in contact with moisture, is commonly used in place of an adhesive. Karaya paste promotes adhesion of the ostomy appliance.