A nurse assessing a client with an ostomy appliance documents the condition "prolapse" in the client chart and notifies the physician. Which of the following statements describes this condition?
A) The peristomal skin is excoriated or irritated because the appliance is cut too large.
B) The system has leaks or poor adhesion leading to noticeable odor.
C) The bag continues to come loose and become inverted.
D) The stoma is protruding into the bag and may become twisted.
Ans: D
During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if stoma is not back to normal size within that time, notify the physician. If stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.
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An older patient with a history of atrial fibrillation is prescribed digoxin 62.5 ?g daily. For which assessment finding should the nurse hold the medication and reassess the patient later?
A) Blood pressure is 98/55 mm Hg B) Heart rate is 60 beats per minute C) Demonstrating agitation and delirium D) Oxygen saturation level is 90% by pulse oximeter
Listening carefully to the Korotkoff sounds as you deflate the blood pressure cuff, you detect the first sound at 146 . It continues until 94, when the sounds are muffled, and eventually the sounds disappear at 40
Using the recommended method, you record this blood pressure as a. 146/94 c. 146/94/40 b. 146/40 d. 94/40/0
One of your measurements yields a reading during physical assessment that seems very doubtful, considering the patient's general condition. If you are still in doubt about the data after rechecking, your best option is to
a. discard the instrument. b. record the initial reading. c. discard the reading and go on to the next assessment. d. seek another qualified nurse to confirm the reading.
Which system is an example of a core clinical application?
a. Scheduling system b. Electronic health record c. Claim scrubber d. Physiologic monitoring system