Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?
A. The skin under the appliance looks red briefly after removing the appliance.
Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.
B. The stoma color is a deep red-purple.
A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.
C. An ascending colostomy delivers liquid feces.
The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.
D. The stoma extends 1/2 inch above the abdomen.
The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.
This question is an excerpt from Nurse Dive's nursing test bank - Interprofessional Care of the Client and Family Across the Lifespan II Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale: Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.
Choice B rationale: A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.
Choice C rationale: The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.
Choice D rationale: The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.
Similar Questions
Which complication is suspected in a client whose blood sugar is less than 30 mg/dL?
A. Seizure
Hypoglycemia (blood sugar less than 30 mg/dL) can lead to seizures due to inadequate glucose supply to the brain.
B. Anorexia
Anorexia (loss of appetite) is not directly associated with low blood sugar but can be a symptom of other conditions.
C. Anhidrosis
Anhidrosis refers to the inability to sweat and is not typically associated with low blood sugar.
D. Bradycardia
Bradycardia (slow heart rate) can be a symptom of severe hypoglycemia but is not the primary complication expected at this blood sugar level.
Full Explanation
Choice A rationale: Hypoglycemia (blood sugar less than 30 mg/dL) can lead to seizures due to inadequate glucose supply to the brain.
Choice B rationale: Anorexia (loss of appetite) is not directly associated with low blood sugar but can be a symptom of other conditions.
Choice C rationale: Anhidrosis refers to the inability to sweat and is not typically associated with low blood sugar.
Choice D rationale: Bradycardia (slow heart rate) can be a symptom of severe hypoglycemia but is not the primary complication expected at this blood sugar level.
A client tells the nurse, "I have intense stomach pain for 3 hours after eating." On assessment the nurse finds abdominal pain and tenderness of the abdomen. The nurse suspects duodenal ulcers in the client. Which diagnostic procedure does the primary health-care provider least likely recommend?
A. Biopsy
Biopsy during an endoscopy can help confirm the presence of duodenal ulcers by analyzing tissue samples.
B. Urea breath test
Urea breath test is used to detect the presence of Helicobacter pylori, a bacterium associated with duodenal ulcers.
C. Endoscopy
Endoscopy is a standard procedure for diagnosing duodenal ulcers by directly visualizing the upper gastrointestinal tract.
D. Computed tomography (CT) scan
While a CT scan can be useful in some cases, it's less commonly used for diagnosing duodenal ulcers compared to other diagnostic methods like endoscopy, biopsy, or urea breath test.
Full Explanation
Choice A rationale: Biopsy during an endoscopy can help confirm the presence of duodenal ulcers by analyzing tissue samples.
Choice B rationale: Urea breath test is used to detect the presence of Helicobacter pylori, a bacterium associated with duodenal ulcers.
Choice C rationale: Endoscopy is a standard procedure for diagnosing duodenal ulcers by directly visualizing the upper gastrointestinal tract.
Choice D rationale: While a CT scan can be useful in some cases, it's less commonly used for diagnosing duodenal ulcers compared to other diagnostic methods like endoscopy,
biopsy, or urea breath test.
A client with diabetes mellitus visits a health care clinic. The client's diabetes previously had been well controlled with glyburide (Diabeta), 5 mg PO daily, but recently, the fasting blood glucose has been running 180-200 mg/dl. Which medication, if added to the clients regimen, may have contributed to the hyperglycemia?
A. phenelzine (Nardil)
Phenelzine is an antidepressant that typically does not affect blood glucose levels significantly.
B. allopurinol (Zyloprim)
Allopurinol, used for gout, is not known to significantly impact blood glucose levels.
C. Metoprolol (Lopressor)
Metoprolol, a beta-blocker, might mask some symptoms of hypoglycemia but is not typically associated with causing hyperglycemia.
D. Methylprednisolone (Medrol pack)
Methylprednisolone, a corticosteroid, can elevate blood glucose levels and might contribute to hyperglycemia in a person with diabetes mellitus. 70.
Full Explanation
Choice A rationale: Phenelzine is an antidepressant that typically does not affect blood glucose levels significantly.
Choice B rationale: Allopurinol, used for gout, is not known to significantly impact blood glucose levels.
Choice C rationale: Metoprolol, a beta-blocker, might mask some symptoms of hypoglycemia but is not typically associated with causing hyperglycemia.
Choice D rationale: Methylprednisolone, a corticosteroid, can elevate blood glucose levels and might contribute to hyperglycemia in a person with diabetes mellitus.