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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Upon assessment of third degree heart block on the monitor, the nurse should first:
- A. Call a code.
- B. Begin cardiopulmonary resuscitation.
- C. Have transcutaneous pacing ready at the bedside.
- D. Prepare for defibrillation.
Correct Answer: C
Rationale: Third-degree heart block may require pacing. Having transcutaneous pacing ready is the first step to manage symptomatic bradycardia.
Which of the following statements indicates the client understands the expected course of Ménière'sdisease?
- A. The disease process will gradually extend to the eyes.
- B. Control of the episodes is usually possible, but a cure is not yet available.
- C. Continued medication therapy will cure the disease.
- D. Bilateral deafness is an inevitable outcome of the disease.
Correct Answer: B
Rationale: Ménière'sdisease is a chronic condition with no cure, but episodes can often be managed with medications, diet, and lifestyle changes, though hearing loss may progress over time.
A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply.
- A. Projectile vomiting.
- B. Significant abdominal distention.
- C. Copious diarrhea.
- D. Rapid onset of dehydration.
- E. Increased bowel sounds.
Correct Answer: A,B,D,E
Rationale: Small intestinal obstruction can cause projectile vomiting (A), abdominal distention (B), rapid dehydration (D) due to fluid loss, and increased bowel sounds (E) proximal to the obstruction. Copious diarrhea (C) is less likely as stool passage is blocked. CN: Physiological adaptation; CL: Analyze
When giving discharge instructions to the client with vasospastic disorder (Raynaud's phenomenon), the nurse should explain that the expected outcome is a total of the symptoms by:
- A. Decreasing the influence of the sympathetic nervous system on the tissues in the hands and feet
- B. Decreasing the pain by producing analgesia
- C. Increasing the blood supply to the affected area
- D. Increasing monoamine oxidase
Correct Answer: C
Rationale: The expected outcome in Raynaud's is increased blood supply to the affected areas by reducing vasospasm, alleviating symptoms like numbness and pallor. Sympathetic nervous system influence, analgesia, and monoamine oxidase are not directly targeted.
The nurse is planning a staff development program related to infection control. Which of the following precautions should the nurse indicate as essential when caring for clients with hepatitis A?
- A. Gowning when entering a client's room.
- B. Wearing a mask when providing care.
- C. Assigning the client to a private room.
- D. Wearing gloves when giving direct care.
Correct Answer: D
Rationale: Hepatitis A is fecal-oral transmitted, so gloves (D) are essential during direct care to prevent contact with contaminated materials. Gowns (A), masks (B), and private rooms (C) are not required.