Unit 7 EAQ
What should the nurse include in dietary teaching for a client with a colostomy? 1 Liquids should be limited to 1 L per day. 2 Non-digestible fiber and fruits should be eliminated. 3 A formed stool is an indicator of constipation. 4 The diet should be adjusted to include foods that result in manageable stools.
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Which nursing action can best prevent infection from a urinary retention catheter? 1 Cleansing the perineum 2 Encouraging adequate fluids 3 Irrigating the catheter once daily 4 Cleansing around the meatus routinely
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A client has a permanent sigmoid colostomy, and colostomy irrigations are prescribed. The client asks the nurse why they are needed. How should the nurse respond? 1 "Less fluid is lost from the intestine." 2 "They help establish an elimination schedule." 3 "They decrease the amount of flatus in the bowel." 4 "Straining is minimized during a bowel movement."
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A client has undergone surgery with general anesthesia. Within how many hours after surgery should the nurse notify the health care provider if the client does not void? 1 4 hours 2 8 hours 3 12 hours 4 16 hours
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The nurse recalls that what scientific principle is basic to caring for a client with an indwelling urinary catheter? 1 Inertia 2 Gravity 3 Osmosis 4 Diffusion
2
Before a treatment requiring informed consent can be performed, what information must the client be given? (Select all that apply.) 1 The cost of the treatment 2 Alternative treatment options 3 The risks and benefits of the treatment 4 The risks involved in refusing the treatment 5 The nature of the problem requiring the treatment
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A client appears depressed since the surgical creation of a colostomy five days ago. The nurse determines that there is some movement toward adaptation to the change in body image when the client: 1 Discusses the necessity of the colostomy 2 Requests the nurse to change the dressing 3 Looks at the face of the nurse during care 4 Stares at the stoma during dressing changes
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A client had a colostomy surgery and is learning how to care for the skin around the stoma. What should the nurse include in the teaching plan for this client? 1 Avoid the use of soap and other irritating agents 2 Rinse with hydrogen peroxide and apply a gauze pad 3 Pour saline over the stoma and firmly wipe away the fecal matter 4 Wash the area gently with soap and water before applying an appliance
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A client who has been caring for a colostomy on the left side of the abdomen for several years is admitted to the hospital for an unrelated health problem. What type of stool should the nurse expect? 1 Pencil-shaped 2 Mucus-coated 3 Loose and liquid 4 Moist and formed
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A nurse is caring for a client with a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy? 1 Mastery of techniques of colostomy care 2 Readiness to accept an altered body function 3 Awareness of available community resources 4 Knowledge of the necessary dietary modifications
2
A client had a colon resection and formation of a colostomy two days ago. What color does the nurse expect the stoma to be when assessing its viability? 1 Pink 2 Gray 3 Brick red 4 Dark purple
3
A client has a permanent colostomy. During the first 24 hours, there is no drainage from the colostomy. The nurse concludes that this is a result of the: 1 Edema after the surgery 2 Absence of intestinal peristalsis 3 Decrease in fluid intake before surgery 4 Effective functioning of the nasogastric tube
2
A day after surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." Which conflict of Erikson's developmental stages is reflected by this comment? 1 Trust versus mistrust 2 Integrity versus despair 3 Industry versus inferiority 4 Generativity versus stagnation
2
A health care provider prescribes a tapwater enema for a 6-month-old infant with suspected Hirschsprung disease. What rationale causes the nurse to question this prescription? 1 Necessary nutrients could be lost. 2 It could cause a fluid and electrolyte imbalance. 3 It could increase the fear of intrusive procedures. 4 The result could cause shock from a sudden drop in temperature.
2
A routine urinalysis is prescribed for a client. What should the nurse do if the specimen cannot be sent immediately to the laboratory? 1 Take no special action. 2 Refrigerate the specimen. 3 Store it in the dirty utility room and send it later. 4 Discard the specimen and collect another specimen later.
2
What effect of povidone-iodine (Betadine) does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture? 1 Makes the skin more supple 2 Avoids drying the skin as does alcohol 3 Eliminates surface bacteria that may contaminate the culture 4 Provides a cooling agent to diminish the feeling from the puncture wound
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A client experiences difficulty in voiding after an indwelling urinary catheter is removed. The nurse determines that this difficulty most likely is related to: 1 Fluid imbalance 2 Sedentary lifestyle 3 Interruption in previous voiding habits 4 Nervous tension following the procedure
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A client had an abdominal cholecystectomy. Postoperatively, the client refuses to deep breathe and cough, saying, "It's too painful." The nurse should: 1 Give pain medication regularly as soon as possible 2 Obtain a prescription to increase the client's pain medication 3 Medicate the client for pain before coughing and deep breathing 4 Substitute incentive spirometry for coughing and deep breathing
3
A client with a recent colostomy expresses concern about the inability to control the passage of gas. The nurse should teach the client to: 1 Eliminate foods high in cellulose 2 Decrease fluid intake at mealtimes 3 Avoid foods that in the past caused flatus 4 Adhere to a bland diet before social events
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A nurse is caring for a client with an indwelling urinary catheter. What is the most important action for the nurse to implement when irrigating the bladder? 1 Use sterile equipment. 2 Instill the fluid under high pressure. 3 Warm the solution to body temperature. 4 Aspirate immediately to ensure return flow.
1
A nurse is instructing a client to use an incentive spirometer. What client action indicates the need for further instruction? 1 Blowing vigorously into the mouthpiece 2 Getting into a chair to use the spirometer 3 Coughing deeply after using the spirometer 4 Using lips to form a seal around the mouthpiece
1
The nurse provides instructions to a client who will be using an incentive spirometer postoperatively. During the client's return demonstration, the nurse concludes that the teaching has been effective when the client: 1 Coughs twice before inhaling deeply through the mouthpiece 2 Uses the incentive spirometer for 10 consecutive breaths an hour 3 Inhales deeply, seals the lips around the mouthpiece, and then exhales 4 Inhales deeply through the mouthpiece, holds the breath for two seconds, and then exhales
4
A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? 1 Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. 2 After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. 3 Clean the insertion site daily using a solution of one part vinegar to two parts water. 4 Change the drainage bag at least once a week as needed.
4
A client with a urinary retention catheter reports discomfort in the bladder and urethra. What should the nurse do first? 1 Milk the tubing gently. 2 Notify the health care provider. 3 Check the patency of the catheter. 4 Irrigate the catheter with prescribed solutions.
3
The nurse provides discharge teaching to a client related to management of the client's new colostomy. The client states, "I hope I can handle all of this at home; it's a lot to remember." What is the nurse's best response? 1 "I'm sure you will be able to do it." 2 "Maybe a family member can do it for you." 3 "You seem to be nervous about going home." 4 "Perhaps you can stay in the hospital another day."
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A physician orders a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? 1 tubing injection port 2 distal end of the tubing 3 urinary drainage bag 4 catheter insertion site
1
After having a transverse colostomy, the client asks what physical effect the surgery will have on future sexual relationships. Which information should the nurse include in a teaching plan for this client? 1 "You will be able to resume usual sexual relationships." 2 "Surgery will temporarily decrease your sexual impulses." 3 "Your sexual activity must be curtailed for several weeks." 4 "Partners should be told about the surgery before any sexual activity."
1
Before discharge, a client who had a colostomy for colorectal cancer questions the nurse about resuming activity. What should the nurse teach the client about activity? 1 "With guidance, a near-normal lifestyle, including complete sexual function, is possible." 2 "Activities of daily living should be resumed as quickly as possible so you avoid being depressed." 3 "Most sports activities, except for swimming, can be resumed based on your overall physical condition." 4 "After surgery, changes in activities must be made to accommodate for the physiological changes caused by the operation.
1
A nurse in the post-anesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the health care provider? 1 Client pushes the airway out. 2 Client has snoring respirations. 3 Respirations of 16 breaths/min are shallow. 4 Systolic blood pressure drops from 130 to 90 mm Hg.
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A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern? 1 Administer a mineral oil enema. 2 Offer one cup of fluid every hour. 3 Manually remove fecal impactions. 4 Offer a cup of prune juice.
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