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Which intervention should the nurse implement for the client who has had an ileal conduit?
- A. Pouch the stoma with a one (1)-inch margin around the stoma.
- B. Refer the client to the United Ostomy Association for discharge teaching.
- C. Report to the health-care provider any decrease in urinary output.
- D. Monitor the stoma for signs and symptoms of infection every shift.
Correct Answer: D
Rationale: Monitoring the stoma for infection (e.g., redness, discharge) prevents complications. Pouching requires a precise fit, not a 1-inch margin; ostomy referrals are secondary; and decreased output is monitored but not always reported immediately.
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The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the HCP?
- A. The pump keeps sounding an alarm indicating the high pressure has been reached.
- B. Intake is 1,800 mL, NGT output is 550 mL, and Foley output is 950 mL.
- C. On auscultation, crackles and rhonchi in all lung fields are noted.
- D. Client has negative pedal edema and an increasing level of consciousness.
Correct Answer: C
Rationale: Crackles and rhonchi suggest pulmonary edema, a critical complication possibly due to fluid overload, requiring immediate HCP notification. Pump alarms, intake/output, and edema status are less urgent unless associated with other critical findings.
The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client?
- A. Fluid volume loss.
- B. Knowledge deficit.
- C. Impaired urinary elimination.
- D. Alteration in comfort.
Correct Answer: D
Rationale: Severe pain (alteration in comfort) is the priority in acute ureteral calculi, as it affects the client’s immediate well-being and requires prompt management. Fluid loss, urinary elimination, and knowledge are secondary.
When the client with an ileal conduit expresses concern about odor, which recommendation by the nurse is most effective?
- A. Place an aspirin tablet in the pouch.
- B. Use a deodorizing pouch spray.
- C. Change the pouch daily.
- D. Avoid acidic foods.
Correct Answer: B
Rationale: Using a deodorizing pouch spray effectively controls odor, addressing the client's concern.
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF?
- A. Administer normal saline IV.
- B. Take vital signs.
- C. Place client on telemetry.
- D. Assess abdominal dressing.
Correct Answer: A
Rationale: A gunshot wound can cause hypovolemia, leading to prerenal ARF. Administering normal saline IV restores volume and perfusion, preventing ARF. Vital signs, telemetry, and dressing assessment are important but secondary to fluid resuscitation.
The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first?
- A. Monitor the client’s urinary output.
- B. Assess the client’s pain and rule out complications.
- C. Increase the client’s oral fluid intake.
- D. Use a safety gait belt when ambulating the client.
Correct Answer: B
Rationale: Severe pain is a hallmark of renal calculi, and complications like obstruction or infection must be ruled out first. Pain assessment guides treatment. Monitoring output, increasing fluids, and using a gait belt are secondary.