Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing teaching for a client who has an ileal conduit following bladder cancer. Which of the following statements by the client indicates a need for the nurse to provide additional teaching?
A. I need to catheterize the stoma several times a day.
This statement indicates a need for further teaching, as it is incorrect. The client does not need to catheterize the stoma, as the urine flows continuously from the ileal conduit to the pouch. Catheterization can cause infection and damage to the stoma.
B. I will need to measure my stoma each week.
This statement is correct, as the client will need to measure the stoma each week for the first 6 to 8 weeks after surgery. The stoma may change in size and shape as it heals, and the client will need to adjust the size of the pouch opening accordingly.
C. I will always have to wear a pouch.
This statement is correct, as the client will always have to wear a pouch to collect the urine. The client can choose from different types of pouches, such as one-piece or two-piece systems, and change them as needed.
D. I need to cleanse around the stoma with soap and water.
This statement is correct, as the client will need to cleanse around the stoma with soap and water at least once a day. This helps to prevent skin irritation and infection. The client should avoid using alcohol, perfumes, or lotions on the stoma.
This question is an excerpt from Nurse Dive's nursing test bank - NS117 T Winter 2023 Monroe college NY PN Fundamental of nursing proctored exam 2. Take the full exam now
Full Explanation
Choice A reason: This statement indicates a need for further teaching, as it is incorrect. The client does not need to catheterize the stoma, as the urine flows continuously from the ileal conduit to the pouch. Catheterization can cause infection and damage to the stoma.
Choice B reason: This statement is correct, as the client will need to measure the stoma each week for the first 6 to 8 weeks after surgery. The stoma may change in size and shape as it heals, and the client will need to adjust the size of the pouch opening accordingly.
Choice C reason: This statement is correct, as the client will always have to wear a pouch to collect the urine. The client can choose from different types of pouches, such as one-piece or two-piece systems, and change them as needed.
Choice D reason: This statement is correct, as the client will need to cleanse around the stoma with soap and water at least once a day. This helps to prevent skin irritation and infection. The client should avoid using alcohol, perfumes, or lotions on the stoma.
Similar Questions
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
A. Position the client supine.
Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
B. Cleanse the perineal area with an antiseptic.
Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
C. Deflate the balloon halfway and then pull out the catheter.
Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
D. Have the client bear down during removal.
Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.
Full Explanation
Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.
A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
A. Ignoring the urge to defecate
Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of stool in the colon. The nurse should advise the client to respond to the urge to defecate as soon as possible and to establish a regular bowel routine.
B. Increased fiber in the diet
Increased fiber in the diet is not a cause of constipation, but rather a prevention measure. Fiber helps to soften the stool and increase its bulk, which facilitates its passage through the colon. The nurse should encourage the client to consume adequate amounts of fiber from fruits, vegetables, whole grains, and legumes.
C. Excessive laxative use
Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependency. The nurse should instruct the client to avoid using laxatives unless prescribed by the provider and to use them only for a short period of time.
D. Increased activity
Increased activity is not a cause of constipation, but rather a prevention measure. Activity helps to stimulate the peristalsis of the colon and promote bowel movements. The nurse should recommend the client to engage in moderate physical activity for at least 30 minutes a day
Full Explanation
Choice A reason: Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of stool in the colon. The nurse should advise the client to respond to the urge to defecate as soon as possible and to establish a regular bowel routine.
Choice B reason: Increased fiber in the diet is not a cause of constipation, but rather a prevention measure. Fiber helps to soften the stool and increase its bulk, which facilitates its passage through the colon. The nurse should encourage the client to consume adequate amounts of fiber from fruits, vegetables, whole grains, and legumes.
Choice C reason: Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependency. The nurse should instruct the client to avoid using laxatives unless prescribed by the provider and to use them only for a short period of time.
Choice D reason: Increased activity is not a cause of constipation, but rather a prevention measure. Activity helps to stimulate the peristalsis of the colon and promote bowel movements. The nurse should recommend the client to engage in moderate physical activity for at least 30 minutes a day
A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?
A. Plan to administer insulin to the client.
Planning to administer insulin to the client is not a relevant action for the nurse to take, as it has no effect on respiratory alkalosis or hyperventilation. Insulin is used to lower blood glucose levels in patients with diabetes or hyperglycemia.
B. Have the client breathe into a paper bag.
Having the client breathe into a paper bag is a correct action for the nurse to take, as it helps to increase the carbon dioxide level in the blood and correct the alkalosis. Breathing into a paper bag creates a closed system that recycles the exhaled carbon dioxide and reduces the loss of carbon dioxide from the lungs.
C. Plan to administer sodium bicarbonate to the client.
Planning to administer sodium bicarbonate to the client is not a correct action for the nurse to take, as it can worsen the alkalosis. Sodium bicarbonate is an alkali that can raise the pH of the blood and cause metabolic alkalosis. It is used to treat metabolic acidosis, not respiratory alkalosis.
D. Have the client place their head between their knees.
Having the client place their head between their knees is not a recommended action for the nurse to take, as it can impair the blood flow to the brain and cause fainting. It can also increase the respiratory rate and decrease the carbon dioxide level in the blood.
Full Explanation
Choice A reason: Planning to administer insulin to the client is not a relevant action for the nurse to take, as it has no effect on respiratory alkalosis or hyperventilation. Insulin is used to lower blood glucose levels in patients with diabetes or hyperglycemia.
Choice B reason: Having the client breathe into a paper bag is a correct action for the nurse to take, as it helps to increase the carbon dioxide level in the blood and correct the alkalosis. Breathing into a paper bag creates a closed system that recycles the exhaled carbon dioxide and reduces the loss of carbon dioxide from the lungs.
Choice C reason: Planning to administer sodium bicarbonate to the client is not a correct action for the nurse to take, as it can worsen the alkalosis. Sodium bicarbonate is an alkali that can raise the pH of the blood and cause metabolic alkalosis. It is used to treat metabolic acidosis, not respiratory alkalosis.
Choice D reason: Having the client place their head between their knees is not a recommended action for the nurse to take, as it can impair the blood flow to the brain and cause fainting. It can also increase the respiratory rate and decrease the carbon dioxide level in the blood.