Nokea
Which complication should the nurse monitor for in a client with a new ileal conduit?
- A. Stoma prolapse.
- B. Urinary retention.
- C. Bladder spasms.
- D. Renal colic.
Correct Answer: A
Rationale: Stoma prolapse is a potential complication of an ileal conduit, requiring surgical correction if severe.
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The client has midcalf pain when walking a block or more. The client states that the discomfort is relieved with rest. The pain is expected when arterial occlusion reaches which of the following percentages?
- A. 20%
- B. 40%
- C. 50%
- D. 100%
Correct Answer: C
Rationale: Claudication typically occurs when arterial occlusion reaches approximately 50%, significantly reducing blood flow to muscles during activity. This causes ischemia and pain, which is relieved by rest when oxygen demand decreases. Complete (100%) occlusion would cause rest pain or tissue necrosis, not just claudication.
The nurse should assess the client with Ménière'sdisease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply.
- A. Antihistamines.
- B. Antiemetics.
- C. Diuretics.
- D. Non-steroidal anti-inflammatory drugs (NSAIDs).
- E. Antipyretics.
Correct Answer: A,B,C
Rationale: Common medications for Ménière'sdisease include antihistamines (e.g., meclizine) to reduce vertigo, antiemetics to control nausea, and diuretics to reduce inner ear fluid, all aimed at symptom management.
A 56-year-old cancer survivor feels guilty at the 'I Can Cope' meetings. The nurse can help him manage his feelings of guilt by pointing out that:
- A. He is really angry at the terminally ill clients in the group.
- B. He is experiencing very volatile emotions.
- C. This is a spiritual response to his illness.
- D. This is a normal reaction when surviving a life-threatening experience.
Correct Answer: D
Rationale: Survivor guilt is a normal reaction for cancer survivors, especially in support groups, and acknowledging this helps the client process their emotions.
The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which of the following are expected normal findings? Select all that apply.
- A. Reduced edema of the left knee.
- B. Skin warm to touch.
- C. Capillary refill response.
- D. A 55-year-old response.
- E. Pain absent.
- F. Pulse on left leg weaker than right leg.
Correct Answer: A,B,C
Rationale: Reduced edema, warm skin, and normal capillary refill are expected post-surgery. Pain is typically present, and pulses should be equal.
There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.
- A. Cut around blood stains to remove clothing.
- B. Place each item of clothing in a separate paper bag.
- C. Allow clothing to dry.
- D. Refrain from documenting client statements.
- E. Place bullets in a sterile container.
Correct Answer: B
Rationale: To preserve forensic evidence, clothing should be placed in separate paper bags to prevent cross-contamination. Cutting around blood stains or placing bullets in sterile containers may damage evidence, and documentation of statements is necessary for legal purposes.