Nokea
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
- A. The skin around the stoma is red.
- B. The urine is a deep yellow.
- C. There is no odor present.
- D. The seal around the stoma is intact.
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.
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A client is admitted from a nursing home with an acute onset of shortness of breath. A diagnosis of pulmonary embolism is made. One common cause of pulmonary embolism is:
- A. Arteriosclerosis
- B. Aneurysm formation
- C. Deep vein thrombosis (DVT)
- D. Varicose veins
Correct Answer: C
Rationale: Deep vein thrombosis (DVT) is a common cause of pulmonary embolism, as clots from the veins (often legs) can dislodge and travel to the lungs, causing acute shortness of breath. Arteriosclerosis, aneurysms, and varicose veins are less directly associated.
Which of the following is most likely to cause the client to experience postoperative nausea and vomiting?
- A. Total hip replacement.
- B. Mitral valve repair.
- C. Abdominal hysterectomy.
- D. Mastectomy of the left breast.
Correct Answer: C
Rationale: Abdominal hysterectomy involves manipulation of the gastrointestinal tract, increasing the risk of postoperative nausea and vomiting due to vagal stimulation and slowed gastric motility.
The nurse is applying a hand mitt restraint for a client with pruritis (see figure). The nurse should be:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: A physician's order is required for restraints to ensure legal and ethical use, prioritizing patient safety and preventing scratching in pruritus.
After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the tube feedings:
- A. Meet the fluid and nutritional needs of the client.
- B. Prevent aspiration.
- C. Prevent fistula formation.
- D. Maintain an open airway.
Correct Answer: A
Rationale: The primary purpose of a feeding tube post-laryngectomy is to meet the client's fluid and nutritional needs, as oral intake may be impaired due to surgical changes.
A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time?
- A. Report hematuria to the physician.
- B. Strain the urine carefully.
- C. Administer meperidine (Demerol) every 3 hours.
- D. Apply warm compresses to the flank area.
Correct Answer: B
Rationale: Straining urine is critical when pain becomes intermittent, indicating possible stone passage, to confirm stone expulsion and guide treatment.