NR224 Final Practice.docx

1. A nurse is teaching a client how to perform personal ileostomy care prior to discharge. The client says “I don’t think that I am going to be able to take care of this myself.” Which is the most appropriate response ...

1. A nurse is teaching a client how to perform personal ileostomy care prior to discharge. The client says “I don’t think that I am going to be able to take care of this myself.” Which is the most appropriate response from the nurse? a. In time you will be better at this than I am. b. Don’t worry about it, most clients feel like you do at first. c. What part of the ileostomy care are you having trouble with? d. I agree. This is a difficult process. This response opens up communication about the client’s real concerns and enables the nurse to address teaching moments to help them feel more confident with self-care. The other responses are not therapeutic and dismiss the client’s concerns. Question 2 The adult child of a client who has had a colon resection will be caring for their parent at home. The client’s son tells the nurse “I don’t know how I am going to care for my mom now”. Which is the best nursing response? a. A home health nurse will be stopping by tomorrow to answer your questions. b. Your mother has been taught to care for her colostomy independently.Correct! c. What part of your mother’s care are you concerned with? d. It is quite simple. I’ll change the colostomy bag before she is discharged. This gives the client an opportunity to discuss their concerns with the nurse. The nurse can then make an appropriate plan to assure the family and client receive any supportive care after discharge. The other responses do not encourage discussion and belittle the son’s concerns. Question 3 A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from PACU. The float nurse is most qualified to care for which client? a. A client who is postoperative following a lobectomy and has a chest tube b. A client who is being discharged to a long-term care facility c. A client who needs teaching prior to initiating cardiac rehabilitation activities d. A client who needs teaching about insulin self-administration Float nurses should be assigned to an area for which they have been trained and have experience. Question 4 A client asks the nurse what causes constipation. Choose the best response by the nurse. Correct Answer a. Constipation occurs when the bowel absorbs too much water b. Eating too many processed foods cause constipation c. When the bowel releases too much water it causes constipation d. Using over the counter laxatives causes constipation Constipation occurs when the large intestine absorbs too much fluid. Clients are encouraged to increase high fiber foods along with drinking plenty of fluids to maintain regularity. Diarrhea is caused when the bowel releases too much water. Using over the counter laxatives may cause diarrhea, not constipation. Question 5 The nurse caring for a post-operative client performs an abdominal assessment. The nurse does not hear any bowel sounds over the left lower quadrant of the abdomen. What is the most likely reason for this? a. The client has been NPO for several hours b. Post-operative clients may develop an ileus resulting in absent bowel sounds c. There is gas in the abdomen d. The client emptied their bowels before surgery An ileus is a portion of the bowel where peristalsis has temporarily slowed or stopped. The nurse will not auscultate bowel sounds in the area of an ileus. NPO status would result in hypoactive bowel sounds throughout the entire abdomen. Gas in the intestine would cause highpitched bowel sounds. Emptying the bowel before surgery would have little to no effect on bowel sounds. Question 6 The nurse admits a client who is to undergo a colonoscopy. The nurse understands that this will be required in preparation for the procedure. a. NPO status for 24 hours b. A complete bowel cleanse c. Clear liquids after midnight d. A fleet enema to prep the bowel Clients who will undergo a colonoscopy usually remain NPO for 8-12 hours prior to the procedure. A complete bowel cleanse is required to rid the area of stool that may interfere with visualization and collection of tissue specimens. A fleet enema alone would not be enough to clear the bowel. Question 7 A nurse is teaching a client about colorectal cancer testing. The nurse expects the provider to first perform this test for colorectal screening. a. Colonoscopy b. Barium enema c. Fecal occult blood test d. Cat scan of the lower intestine The provider will first do a fecal occult blood (guiac) test to determine the presence of microscopic blood in the stool. This is often an early sign of colorectal cancer. The other procedures may be done as a follow-up to the guiac test. Question 8 A nurse is caring for a client with a newly placed colostomy. The nurse teaches the client they may have formed stool after the bowel has healed because the surgeon placed the stoma where? You Answered a. Ascending colon b. Transverse colon c. Descending colon d. Sigmoid colon Ostomies placed in the sigmoid colon may eventually have formed stool. The lower down in the colon that the ostomy is placed, the more likely the client will have formed stool. Higher ostomy positioning results in liquid or semi-formed stool. Question 9 The nurse is administering a tap water enema to a client in preparation for bowel surgery. The nurse correctly positions the enema bag containing the fluid where? a. 12 inches above the anus for a regular enemaou Answered b. 6-10 inches above the anus for a high enema c. To shoulder height then lower it 6 inches d. On an IV pole 18 inches above the bed The correct placement for a regular enema is to hold the container 12 inches above the client’s anus. Question 10 The nurse correctly positions a client for a fleets enema by placing them in this position: a. Supine with the knees flexed b. Prone with the right leg flexed c. On the left side with the right leg flexed d. On the right side with both knees flexed Correct positioning for administering an enema is to place the client on their left side with their right leg bent to follow the natural curve of the colon. Question 11 The nurse is preparing a new ostomy flange for the client’s abdomen. Choose the correct action by the nurse. a. Scrub the skin on the abdomen with antiseptic soapnswered b. Report the appearance of a red, moist stoma c. After measuring the diameter of the stoma cut the opening of the wafer d. Tape the wafer in place in a window-pane format The nurse must carefully measure the diameter of the stoma and cut the wafer to fit, leaving 1/8 “ around the stoma to prevent skin breakdown and allow for adequate circulation to the stoma. The skin under the wafer should be gently cleansed and prepped with an adhesive wipe. A red, moist stoma is normal. The wafer does not need to be taped in place as it has its own selfadhesive surface that contacts the client’s skin. Question 12 The nurse would plan to perform more frequent perineal care to prevent skin breakdown for this client. a. Client with an indwelling catheter b. Client who uses a walker to ambulate c. Client with urinary frequency d. Client with an incision on their abdomen The client with urinary frequency will need more frequent skin care due to the caustic effects of urine sitting on the skin for prolonged periods. A client with indwelling catheter would not have urine on the skin. The client who uses a walker does not necessarily have any problem with continence. A client with an abdominal incision does not need special perineal care. Question 13 A female nurse is upset because a male client has requested only a male nurse help them with personal care. What is the best response from the charge nurse? a. The female nurse should ask the client what they did to offend them. b. The client may have gender identity issues. c. The client may have been abused by their mother. d. The client’s religious beliefs may prevent a female care-giver.