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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The nurse is developing a care plan with a client who had a laryngectomy 3 days ago. The nurse should instruct the client to do which of the following to assure adequate nutrition. Select all that apply.
- A. Weigh weekly and report weight loss.
- B. When eating, sit and lean slightly forward.
- C. Have serum albumin level checked regularly.
- D. Administer enteral tube feedings as ordered.
- E. Manipulate the nasogastric tube daily.
Correct Answer: A,B,C,D
Rationale: To ensure adequate nutrition post-laryngectomy, the client should monitor weight, sit and lean forward to aid swallowing, check serum albumin for nutritional status, and use enteral feedings as ordered. Manipulating the tube is not recommended to avoid dislodgement.
Which of the following represents the most appropriate nursing intervention for a client with pruritus caused by cancer or the treatment?
- A. Administration of antihistamines.
- B. Steroids.
- C. Silk sheets.
- D. Medicated cool baths.
Correct Answer: D
Rationale: Medicated cool baths soothe the skin and reduce pruritus, a common symptom in cancer patients, without the systemic effects of antihistamines or steroids.
A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? Select all that apply.
- A. Rapid pulse.
- B. Decreased energy and fatigue.
- C. Weight gain of 10 lb.
- D. Fine, thin hair with hair loss.
- E. Constipation.
- F. Menorrhagia.
Correct Answer: B,C,D,E,F
Rationale: Hypothyroidism slows metabolism, leading to decreased energy, fatigue, weight gain, hair loss, constipation, and heavy menstrual periods (menorrhagia). Rapid pulse is associated with hyperthyroidism, not hypothyroidism.
An elderly client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the client should be made to be removed for which of the following complications?
- A. Vertigo.
- B. Bell's palsy.
- C. Hypoventilation.
- D. Loss of gag reflex.
Correct Answer: C
Rationale: Posterior packing can obstruct the airway, leading to hypoventilation, a serious complication. Vertigo, Bell's palsy, and loss of gag reflex are not directly associated with posterior packing.
The client asks the nurse whether he will need surgery to correct his hiatal hernia. Which reply by the nurse would be most accurate?
- A. Surgery is usually required, although medical treatment is attempted first.'
- B. Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes.'
- C. Surgery is not performed for this type of hernia.'
- D. A minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned.'
Correct Answer: B
Rationale: Most hiatal hernias are managed effectively with diet, medications, and lifestyle changes, making this the most accurate response.