Certified Medical-Surgical Registered Nurse Questions and Answers with Rationale 100% Verified | RATED A+
Question : The nurse receives all of the following stat orders
for Mr. Palmer. Which one should the nurse question?
Oxygen per nasal cannula at 4 L per minute.
Enoxaparin (Lovenox) 40 mg subcutaneously.
Troponin level.
Computed tomography (CT) angiogram.
Correct answer: 1) Oxygen per nasal cannula at 4 L per
minute.
Rationale: The nurse should questions the order for Lovenox
because the patient is receiving a heparin drip.
Question : 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 proctocolectomy and a permanent ileostomy 12 hours ago.The nurse should contact the physician immediately if Mrs.Warren has which of these findings?
The stoma appears pale and dry.
The stoma appears red and shiny.
There is 200 mL of dark green output from the stoma.
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.
Question : 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?
Wash the area with antiseptic soap and water.
Clean the site with Dakin's solution.
Use a solid skin barrier.
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.
Question : Which of these comments, if made by Mrs. Warren
before her surgery, would indicate that she had concerns about her body image?
"I will have to stop my aerobics classes."
"I'm so afraid I may not survive the surgery."
"I need to go shopping for some loose, baggy clothes."
"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