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Questions 149

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Question 1 of 5

Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?

Correct Answer: B

Rationale: Antibiotics can reduce the effectiveness of oral contraceptives, necessitating an alternate method.

Question 2 of 5

The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last

Order the Items

Source Container

Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
Apply the irrigation sleeve over the stoma.
Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.

Correct Answer: E,D,C,B,A

Rationale: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.

Question 3 of 5

Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:

Correct Answer: C

Rationale: A pulse rate below 60 bpm is a contraindication for digoxin administration due to the risk of worsening bradycardia, so the nurse should withhold the dose and notify the physician.

Question 4 of 5

Which of the following roommates would be best for the client newly admitted with gastric resection?

Correct Answer: C

Rationale: Gastritis aligns with gastric resection, posing no infection risk.

Question 5 of 5

If a client has had repair of a right fractured hip and has an overhead trapeze on the bed to assist with movement, which of the following instructions should the client receive about use of the assistive device? Select all that apply.

Correct Answer: A,C

Rationale: Using both hands on the trapeze (
A) and flexing the left leg (
C) assist safe movement post-right hip repair. Using one hand (
B) or keeping the leg extended (
D) is less effective.

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