A nurse is preparing discharge teaching for a client who has Crohn's disease and a new ileostomy. Which of the following community resources should the nurse include in the teaching?
Hospice care services
Long-term care facility
Rehabilitation center
Visiting nurse services
The Correct Answer is D
A. Hospice care services: Hospice care is designed for clients with terminal illnesses who require end-of-life care. Crohn’s disease and an ileostomy do not indicate a terminal condition, making hospice services inappropriate for this client.
B. Long-term care facility: Long-term care facilities are for clients who need continuous medical or personal care and are unable to live independently. Most clients with an ileostomy can manage their care at home with proper education and support, making this resource unnecessary.
C. Rehabilitation center: Rehabilitation centers are primarily for clients recovering from major injuries, strokes, or surgeries that impair mobility or function. While an ileostomy requires adjustment, it does not typically necessitate inpatient rehabilitation.
D. Visiting nurse services: Home health nurses provide essential support for clients with a new ileostomy by assisting with ostomy care, monitoring for complications, and reinforcing self-care education. This service helps facilitate a smoother transition to independent ostomy management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Use the incentive spirometer every 4 hours.": Incentive spirometry is typically recommended every 1 to 2 hours while awake to promote lung expansion and prevent atelectasis. Less frequent use may not provide adequate lung re-expansion, especially after surgery.
B. "Avoid coughing during and after the session.": Coughing is encouraged after using an incentive spirometer to help clear secretions and prevent respiratory complications such as pneumonia. Suppressing a cough can lead to mucus retention and increased risk of infection.
C. "Remove the mouthpiece and exhale quickly.": The client should exhale normally before using the spirometer, then inhale slowly through the mouthpiece to maximize lung expansion. Rapid exhalation does not promote adequate alveolar inflation.
D. "Place the mouthpiece in your mouth and inhale slowly.": Slow, deep inhalation through the spirometer allows for maximum lung expansion, reducing the risk of atelectasis. The client should maintain a steady breath to ensure optimal lung inflation and hold it for a few seconds before exhaling.
Correct Answer is ["A","B","E"]
Explanation
A. Verify the solution with another RN prior to infusion: TPN is a high-risk therapy that requires verification by two RNs to ensure the correct formulation, preventing medication errors that could lead to severe complications.
B. Monitor serum blood glucose during infusion: TPN contains high concentrations of glucose, increasing the risk of hyperglycemia. Regular blood glucose monitoring helps detect imbalances and allows for timely intervention.
C. Increase the rate of infusion if administration is delayed: Increasing the infusion rate can lead to metabolic complications such as hyperglycemia and fluid overload. If TPN is delayed, the provider should be consulted for adjustments rather than increasing the rate independently.
D. Infuse 0.9% sodium chloride if the solution is not available: If TPN is unavailable, the correct alternative is an infusion of dextrose 10% in water (D10W) to prevent hypoglycemia, not 0.9% sodium chloride, which lacks glucose.
E. Obtain the client's weight daily: Daily weights help monitor fluid balance, nutritional status, and potential complications such as fluid retention or dehydration, ensuring proper TPN management.
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