Christine Warren, 45 years old, has a long history of ulcerative colitis, and non-surgical treatment no longer relieved her symptoms. She underwent a total... [Show More] proctocolectomy and a permanent ileostomy 12 hours ago.
The nurse should contact the physician immediately if Mrs. Warren has which of these findings?
1) The stoma appears pale and dry.
2) The stoma appears red and shiny.
3) There is 200 mL of dark green output from the stoma.
4) There is 50 mL of serosanguinous drainage from the stoma. - correct answer 1) The stoma appears pale and dry.
Rationale: If there is an adequate blood supply to the stoma, the color is pink or red, and the stoma is moist as a result of mucous production. A pale dry color suggests ischemia of the stoma or bowel and must be reported immediately to the physician. With an ileostomy initially after surgery, the output is a loose, dark green liquid that may contain some blood. The ileostomy usually begins to drain within 24 of surgery at more than one liter per day.
When changing Mrs. Warren's ileostomy bag, the nurse notices that the peristomal skin is irritated.
Which of these actions by the nurse would be appropriate before reapplying the appliance?
1) Wash the area with antiseptic soap and water.
2) Clean the site with Dakin's solution.
3) Use a solid skin barrier.
4) Obtain an order for a topical antibiotic. - correct answer 3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly irritate the surrounding tissue. Therefore, a solid skin barrier, with a pectin base or karaya wafer that has a measurable thickness and hydrocolloid adhesive properties, should be applied.
Which of these comments, if made by Mrs. Warren before her surgery, would indicate that she had concerns about her body image?
1) "I will have to stop my aerobics classes."
2) "I'm so afraid I may not survive the surgery."
3) "I need to go shopping for some loose, baggy clothes."
4) "I'm concerned that this may be only the first of many surgeries." - correct answer 3) "I need to go shopping for some loose, baggy clothes."
Rationale:Body image refers to a person's perception of self and determines how the person interacts with others. One does not need to purchase special clothing after ileostomy surgery, although some minor adjustments may be needed for comfort, e.g., stretch underwear or pantyhose for support.
Lewis Palmer, 45 years old, has a history of multiple myocardial infarctions and is a heavy smoker. He takes warfarin sodium (Coumadin) daily. Two weeks ago, he had a right femoral-popliteal bypass, which became occluded 24 hours ago. He is admitted following an angioplasty of the femoral-popliteal bypass graft. Mr. Palmer is receiving continuous IV heparin.
Because Mr. Palmer is receiving heparin, it is essential for the nurse to
1) monitor his prothrombin time.
2) observe him for signs of pulmonary embolism.
3) limit his intake of foods high in vitamin K.
4) check the femoral puncture site at frequent intervals. - correct answer 4) check the femoral puncture site at frequent intervals.
Rationale: Since bleeding is a common side effect of heparin, it is vital to check the operative site, the femoral puncture area, for signs of bleeding.
Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr. Palmer has a below-knee amputation (BKA) of his right extremity and is returned to the medical-surgical unit with an intravenous infusion in place. His orders include: heparin drip, morphine sulfate 10 mg IV push q4h prn for pain, and ampicillin sodium g 1 IV q6h.
Twelve hours postoperatively, Mr. Palmer is found to be short of breath and diaphoretic. He says, "My chest hurts." His pulse is 140/min, compared to a baseline of 80/min. His blood pressure is105/60 mm Hg, compared to a baseline of 138/70 mm Hg. His respirations are 32/min, compared to a baseline of 16/min. His O2 saturation is 85%. The nurse immediately calls for help. Which of the following questions is most important for the nurse to ask?
1) "Have you ever had this type of chest pain before?"
2) "How long have you had this pain?"
3) "What pain medication do you usually take?"
4) "What were you doing before the pain began?" - correct answer 1) "Have you ever had this type of chest pain before?"
Rationale: Because of the patient's symptoms and his history of myocardial infarctions, the nurse should find out if the patient has had this time of pain previously.
The nurse receives all of the following stat orders for Mr. Palmer. Which one should the nurse question?
1) Oxygen per nasal cannula at 4 L per minute.
2) Enoxaparin (Lovenox) 40 mg subcutaneously.
3) Troponin level.
4) Computed tomography (CT) angiogram. - correct answer Rationale: The nurse should questions the order for Lovenox because the patient is receiving a heparin drip.
Maggie Clark, a 42-year-old female, was admitted with newly diagnosed type 2 diabetes mellitus. Her blood glucose has been stabilized, and the nurse is preparing her for discharge. Her discharge orders will include metformin (Glucophage). Mrs. Clark is also being treated for hypertension.
Because Mrs. Clark is to take Glucophage on a regular basis it is important to
1) monitor her glomerular filtration rate.
2) check her serum amylase routinely.
3) obtain her red blood cell count periodically.
4) examine her urine for casts. - correct answer 1) monitor her glomerular filtration rate.
Rationale: The estimated glomerular filtration rate (eGFR) is one way to measure the adequacy of kidney function. Glucophage is excreted by the kidney and the risk of lactic acidosis increases in patients with impaired kidney function. The drug may be used if the eGFR is between 45 and 60 mL/min/1.73 m2, i.e., in mild chronic kidney disease. Glucophage is absolutely contraindicated if the eGFR is below 30 mL/min/1.73 m2.
Mrs. Clark is prescribed metoprolol tartrate (Lopressor) for hypertension. Which symptom of hypoglycemia would be masked by Lopressor?
1) Diaphoresis.
2) Tingling.
3) Diplopia.
4) Tachycardia. - correct answer 4) Tachycardia.
Rationale: A side effect of Lopressor, a beta blocker, is bradycardia. The Lopressor-induced bradycardia can mask tachycardia, a symptom of hypoglycemia.
Charles Haverford is diagnosed with prostate cancer and is to have a radical prostatectomy.
Mr. Haverford has been researching his diagnosis and now asks the nurse to recommend a reliable web source for accurate prostate cancer information. The nurse should identify which of these websites as most reliable?
1) www.wikipedia.org.
2) www.cancer.gov.
3) www.caringbridge.org.
4) www.google.com. - correct answer 2) www.cancer.gov.
Rationale: When a patient asks about researching information on the internet, the patient should be instructed to look at reliable sites. Sites that are most reliable are those sponsored by the government (.gov).
Mr. Haverford has the planned surgery and immediately postoperatively he has a urinary catheter inserted. After the urinary catheter is removed Mr. Haverford is urinating normally, however he is experiencing occasional incontinence with dribbling. Mr. Haverford is to be discharged.
Mr. Haverford says to the nurse, "I'm so embarrassed. What will my wife think about this dribbling?" In addition to acknowledging his feelings, the nurse should encourage the patient to
1) limit oral intake of fluids before bedtime.
2) palpate his bladder to check for distention three times a day.
3) perform pelvic floor exercises several times daily.
4) avoid interrupting the urinary stream during voiding. - correct answer 3) perform pelvic floor exercises several times daily.
Rationale: It is not unusual for a patient who has had a prostatectomy, to complain of not having complete bladder control after catheter removal. To help the patient regain urinary control, pelvic floor strengthening exercises are recommended.
A patient's wife is visibly upset and says to the nurse, "I thought my husband only broke his hip, but the doctor thinks he might have had a stroke." Which of the following would be an appropriate response by the nurse?
1) "It's really too early to be concerned about that. Let's wait until the test results come back."
2) "If it is a stroke, your husband is in the right hospital for treatment."
3) "Yes, he does have symptoms of a stroke. That's what the tests will help us find out."
4) "I'm going to get you some information to read about strokes and their treatment." - correct answer 3) "Yes, he does have symptoms of a stroke. That's what the tests will help us find out."
Rationale: Symptoms of stroke vary greatly and the initial diagnosis is made after a non-contrast CT scan is done to determine if the event was ischemic or hemorrhagic. Then, further tests are done to confirm the diagnosis and decide on treatment.
In the event of a fire in a hospital's dialysis unit, which of these actions should the nurse take first?
1) Extinguish the fire if possible.
2) Activate the fire response system.
3) Confine the fire by closing all fire doors.
4) Remove patients or staff in danger. - correct answer 4) Remove patients or staff in danger.
Rationale: When a fire occurs in a patient area within the hospital, the nurses' first actions are to protect patients and staff. This usually involves removing the patients and staff from exposure to the fire.
An 80-year-old male who has mild dementia is readmitted for the third time with multiple pressure ulcers. During the nursing assessment, multiple bruises are also observed on his body. He lives with his son and daughter-in-law. The nurse suspects elder abuse/neglect. Which of these actions should the nurse take?
1) Have a staff member present during family visits.
2) Report the findings.
3) Discuss the situation with the family.
4) Ask the patient who is providing his care. - correct answer 2) Report the findings.
Rationale: Most states require that health care workers report suspected elder abuse to an official agency, such as Adult Protective Services.
A patient who has active pulmonary tuberculosis (TB) states, "I'm not going to take these TB pills!" Which of these responses by the nurse would be appropriate?
1) "You have a legal right to refuse to take this medication."
2) "You need to sign a Refusal of Treatment Form."
3) "You need to ask your doctor about the possibility of discontinuing the medication."
4) "You should know that the health department can require you to take the medication." - correct answer 4) "You should know that the health department can require you to take the medication."
Rationale: Tuberculosis (TB) is a public health problem that requires reporting of the disease to the health department. It is essential that the patient understand the need to take prescribed TB medications as directed. Patients who are unwilling or unable to adhere to treatment may be required to do so by law or may be quarantined or isolated until noninfectious. State governments have legal responsibility for TB control activities, including treatment protocols for nonadherent patients. Health care workers should be familiar with the law in their particular states for these procedures.
When a patient is having a chest tube removed, which of these instructions would be appropriate? [Show Less]
