Nokea
When changing a client's colostomy pouch and noticing peristomal skin irritation, which of the following actions should the nurse take?
- A. Change the pouch as needed based on individual requirements.
- B. Apply the pouch only when the skin barrier is completely dry.
- C. Pat the peristomal skin dry after cleaning.
- D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.
Correct Answer: D
Rationale: When a nurse observes peristomal skin irritation while changing a client's colostomy pouch, it is crucial to ensure that the pouch is slightly larger (0.32 cm or 1/8 inch) than the stoma. This extra space helps prevent the pouch from rubbing against the stoma and causing further irritation. Option A is correct because colostomy pouches should be changed based on individual needs, not necessarily every 24 hours. Option B is incorrect because applying the pouch only when the skin barrier is completely dry ensures better adhesion. Option C is incorrect as patting the peristomal skin dry after cleaning is more gentle and less likely to cause irritation compared to rubbing.
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When should discharge planning for a patient admitted to the neurological unit with a diagnosis of stroke begin?
- A. At the time of admission
- B. The day before the patient is to be discharged
- C. When outpatient therapy is no longer needed
- D. As soon as the patient's discharge destination is known
Correct Answer: A
Rationale: Discharge planning for a patient admitted to the neurological unit with a stroke diagnosis should begin at the time of admission. Initiating discharge planning early allows for a comprehensive assessment of the patient's needs, enables better coordination of care, and ensures a smooth transition from the hospital to the next level of care. Option B is incorrect because waiting until the day before discharge does not provide enough time for adequate planning. Option C is incorrect because waiting until outpatient therapy is no longer needed delays the planning process. Option D is incorrect because waiting until the discharge destination is known may result in rushed planning and inadequate preparation for the patient's needs.
A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?
- A. Determine the client's sleep and activity patterns
- B. Obtain a prescription for the client to take when stressed
- C. Refer the client for a sleep study and neurological follow-up
- D. Teach coping strategies to use when feeling stressed
Correct Answer: A
Rationale: Assessing the client's sleep and activity patterns is crucial in understanding the factors contributing to the sleep difficulties and headaches. By evaluating these patterns, the nurse can identify triggers, stressors, and lifestyle habits that may be impacting the client's sleep quality and overall well-being. This assessment will guide the nurse in formulating an appropriate care plan tailored to the client's specific needs. Option B is not appropriate as it focuses solely on providing medication without addressing underlying issues. Option C is premature as a thorough assessment should precede any referrals for specialized studies. Option D, while important, should come after understanding the client's sleep patterns to provide more targeted coping strategies.
A post-op nurse has an indwelling catheter in place for gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:
- A. Check to see if the tubing is kinked.
- B. Increase the IV fluid rate.
- C. Check the catheter insertion site.
- D. Contact the healthcare provider.
Correct Answer: A
Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
- A. When do you usually bathe, in the morning or evening?
- B. Do you prefer a bath or a shower?
- C. At what temperature do you prefer your bath water?
- D. Are you able to help with your hygiene care?
Correct Answer: D
Rationale: The priority assessment question before beginning hygiene care for a new resident is determining if the resident is able to help with their hygiene care. This is essential to ensure the resident's safety during the procedure and prevent any potential injuries. Options A, B, and C, while relevant to providing personalized care, are not as critical as assessing the resident's ability to participate in their own hygiene care. Asking about the resident's ability to assist also promotes their independence and autonomy in self-care activities.
An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?
- A. Help the client write down the questions to ask the provider, so that the client doesn't forget
- B. Reassure the client that everything will be explained
- C. Explain the procedure in detail yourself
- D. Direct the client to search for information online
Correct Answer: A
Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.