Evolve Questions
A client just has returned from the postanesthesia care unit after having a laparotomy. Which initial sign or symptom indicates to the nurse that peristalsis has begun to return? 1 Stool is evacuated. 2 Nausea is no longer present. 3 Borborygmi are auscultated. 4 Abdomen is no longer tender.
3 Borborygmi are auscultated. The nurse auscultates the abdomen and listens for bowel sounds (borborygmi), which signify the initial return of peristalsis. The first bowel movement occurs after peristalsis returns. Nausea and/or tenderness may be present, even though peristalsis has returned.
Three days after surgery for cancer of the colon, a nurse introduces the client to colostomy care. Which should the nurse teach the client about skin care around the stoma? 1 Apply liberal amounts of Vaseline for 3 inches (7.6 centimeters) around the stoma 2 Wash the area with soap and water and then apply a protective ointment 3Pour saline over the stoma and rub the area to remove hard fecal matter 4 Rinse the area with peroxide before applying fresh gauze bandages
2 Wash the area with soap and water and then apply a protective ointment Using soap and water and ointment helps maintain skin integrity and prevent infection. Applying an ointment to the extent of 3 inches (7.6 centimeters) is contraindicated because it will interfere with adherence of the appliance. Rubbing may be irritating and may promote conditions that contribute to infection. Soap and water are adequate unless peroxide is specifically prescribed by the healthcare provider; gauze bandages generally are not applied around or over a stoma.
A nurse is caring for an adult client with acromegaly. What clinical manifestation does the nurse expect the client to exhibit? 1 Prominent jaw 2 Decreased pulse 3 Increased height 4 Increased sodium
1 Prominent jaw Acromegaly is caused by increased secretion of growth hormone in adults after full growth and epiphyseal closure; it causes enlargement of bones and soft tissue of the lower jaw, cheeks, hands, and feet. The pulse rate is not affected. Increased growth hormone causes gigantism in children before epiphyseal closure of long bones. Sodium levels are not affected.
The primary healthcare provider confirms that the client has myopia. Which type of test did the nurse perform to help the primary healthcare provider reach this conclusion? 1 Perimetry 2 Jaeger card 3 Ishihara chart 4 Snellen eye chart
4 Snellen eye chart Myopia indicates nearsightedness. This is a condition in which a client cannot see distant images clearly, and the Snellen eye chart is used to measure distance vision. Perimetry is the computerized test performed to determine the degree of peripheral vision. The Rosenbaum Pocket Vision screener or a Jaeger card is the eye chart used to determine near vision. An Ishihara chart is used to determine a client's ability to see colors.
In what ways can a nurse prevent medication errors? Select all that apply. 1 Avoid using abbreviations and acronyms 2 Minimize the use of verbal and telephone orders 3 Try to guess what the client is saying if the language is not understood 4 Document each dose of the drug using trailing zeros when recording the dose 5 Check three times before giving a drug by comparing the drug order and medication profile
1 Avoid using abbreviations and acronyms 2 Minimize the use of verbal and telephone orders 5 Check three times before giving a drug by comparing the drug order and medication profile The use of abbreviations is avoided because this action may cause confusion and increase the risk of error. The use of verbal and telephone orders should be minimized to avoid confusion over drugs that have similar names. Before a drug is administered, the dosage order should be checked three times to verify the five rights: right drug, right dose, right time, right route, and right client. The use of trailing zeros should be avoided because it increases the risk of overdose. If the client's language is not understood, a translator's help should be enlisted.
A nurse is administering an intradermal skin test injection to a client. What is the next action the nurse needs to do after the medication has been injected? 1 Withdraw the needle and place a piece of gauze over the injection site. 2 Withdraw the needle and scrub the site with Betadine solution. 3 Withdraw the needle and vigorously wipe the area with an alcohol wipe. 4 Withdraw the needle and circle the area with a skin pen.
1 Withdraw the needle and place a piece of gauze over the injection site. Gently placing a piece of gauze at the injection site is necessary to prevent the intradermal medication from leaking out of the injection site. Scrubbing the site with Betadine or vigorously wiping with alcohol can cause the medication to leak into the surrounding tissue and prevent the accuracy of the test. Circling the area with a skin pen needs to be done after the gauze has been applied to the area and then removed.
A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply. 1 "I may eat potatoes at dinner daily." 2 "I should drink at least six glasses of water every day." 3 "I must eat eggs for breakfast three times a week." 4 "I can include bran muffins in my breakfast daily." 5 "I will walk every day as part of my exercise regimen."
2 "I should drink at least six glasses of water every day." 4 "I can include bran muffins in my breakfast daily." 5 "I will walk every day as part of my exercise regimen." At least six glasses of water keeps the feces soft, which prevents constipation. Whole grains such as bran muffins are high in roughage, which prevents constipation. Walking increases intestinal motility, which helps prevent constipation. Potatoes and eggs do not contain roughage and will not prevent constipation.
1. After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis? 1 Nodules on the pinna 2 Redness of the eardrum 3 Lesions in the external canal 4 Excessive soft cerumen in the external canal
2 Redness of the eardrum Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination. Nodules on the pinna may be an indication of rheumatoid arthritis, chronic gout, or basal or squamous cell carcinoma. Lesions in the external canal may cause a decrease in hearing acuity but not the manifestation of otitis media. Excessive soft cerumen in the external canal impacts the hearing acuity but not the manifestation of otitis media.
A client is experiencing chronic constipation, and the nurse discusses how to include more bulk in the diet. Which statement by the client indicates teaching by the nurse is successful? 1 "Bulk promotes defecation by irritating the bowel wall." 2 "Bulk promotes defecation by stimulating the intestinal mucosa chemically." 3 "Bulk promotes defecation by acting on the microorganisms in the large intestine." 4 "Bulk promotes defecation by absorbing water, which softens stool and promotes peristalsis."
4 "Bulk promotes defecation by absorbing water, which softens stool and promotes peristalsis." Fiber provides bulk. Fiber absorbs water, swells, and softens hard stool, promoting peristalsis, mass movements, and defecation. Bulk caused by fiber does not irritate the bowel wall. There is no chemical stimulation. Bacterial action is not involved in the process by which bulk stimulates defecation.
A client had a colostomy surgery and is learning how to care for the skin around the stoma. Which information should the nurse include in the teaching plan for this client? 1 "Cut an opening about ⅓ inch (0.85 cm) larger than the stomal pattern." 2 "Avoid the use of soap and other irritating agents." 3 "Eat yogurt and drink buttermilk and parsley." 4 "Empty the pouch before it is one-third full."
4 "Empty the pouch before it is one-third full." The weight of drainage from the stoma pulls the wafer away from the skin, promoting skin breakdown. For this reason, ostomy bags should be emptied when one-third full. Although irritating agents should not be used, soap is the agent of choice to cleanse the skin around the stoma. Teach the client and family caregiver to trace the pattern of the stomal area on the wafer portion of the appliance and to cut an opening about 1/8 to 1/16 inch (0.32to 0.16 cm) larger than the stomal pattern to ensure that stomal tissue will not be constricted, promoting skin breakdown. Yogurt, buttermilk, and parsley will help with odor but not with skin breakdown.
