Questions and Answers
What is the main purpose of restricting the client's diet to clear liquids initially?
Which of the following is a sign that should be assessed when evaluating vomitus?
What technique is recommended to help a client experiencing nausea?
Why should gloves be worn when assisting a client who is vomiting?
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The presence of coffee-ground material in vomitus is indicative of what?
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What does the term ‘vomitus’ refer to?
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What is one key action to take when monitoring a client's intake and output (I&O) related to vomiting?
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What is a recommended method to help soothe a client who is experiencing nausea?
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What is a primary reason for observing the condition of a new stoma?
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Why is cleanliness particularly emphasized for clients with a stoma before mealtime?
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When changing an ileostomy appliance, why should the nurse check for undissolved medications?
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What should be avoided when caring for the skin around a stoma?
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What is the recommended action if redness or yeast-appearing growth appears around a stoma?
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How can Stomahesive products assist in stoma care?
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What is a primary disadvantage of using soap and alcohol in stoma care?
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What is the benefit of using a drain tube attachment device (DTAD) in stoma care?
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Why is it important for a client to maintain the Sims' position for 15 to 20 minutes after administering a suppository?
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What is the primary reason for wearing gloves and considering a face shield while administering an enema?
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What should be checked before administering a latex-containing enema?
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How should enema solutions be stored to ensure safety and efficacy?
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Why is it crucial to review the provider's order before administering an enema?
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After administering an enema, when should the nurse check on the client?
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What is the rationale for asking the client to lie on their left side during enema administration?
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What could be a consequence of administering an incorrect type of enema solution?
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What position should a female client assume for optimal catheterization?
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What equipment should be checked frequently in a client with a retention catheter?
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How should the catheter tubing be positioned when a client is in bed?
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What should be done to secure the catheter for a male client?
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What potential anatomical challenge is associated with male catheterization?
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How should the collection bag be positioned in relation to the bladder?
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What is necessary when changing the catheter?
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What should be monitored to ensure proper function of the catheter?
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What is a key characteristic of cutaneous urinary diversions?
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Which of the following is a nursing intervention for urinary retention?
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What is an aspect of nursing considerations for clients with urinary diversions?
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Continence diversions differ from cutaneous diversions by:
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What potential impact can a urinary diversion have on a client?
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Which type of urinary incontinence involves a person retaining urine?
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What should nurses prioritize when caring for clients with urinary diversions?
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Which statement best describes a client’s need following a urinary diversion?
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Study Notes
Dietary Recommendations
- Initiate treatment with a clear liquid diet, gradually reintroducing fluids and solid foods.
- Teach clients and families how to prevent food contamination from S.aureus and Salmonella to avoid diarrhea.
Nausea and Vomiting Management
- Nausea is an unpleasant sensation, often leading to vomiting (emesis), which is involuntary.
- Use cool, damp washcloths on the client's forehead to soothe and promote relaxation, potentially reducing vomiting.
- Encourage slow, deep nasal breaths; this technique helps relax the client and reduces the sensation of nausea through increased oxygen flow.
Vomitus Assessment
- Examine vomitus for particles, color, odor, and consistency; bright red blood indicates gastric/esophageal bleeding, while coffee-ground material suggests lower digestive tract bleeding.
- Document the nature of vomiting (violent or projectile) and gather the client’s description of the episode for thorough assessment.
- Consider vomitus as part of the client's intake and output (I&O) monitoring. All observations should be documented, and gloves must be worn during assistance due to body fluid exposure.
Enema Administration Guidelines
- Perform hand hygiene and always wear gloves; consider a face shield if there's splash risk.
- Verify client has no latex allergy before administering a latex-containing enema.
- Use correct enema type and amount based on healthcare provider’s order, especially for children.
- Instruct the client to lie on their left side for optimal enema administration.
Stoma Care
- Regularly check the condition of the stoma, especially if newly established, as size and condition changes may require intervention.
- Ensure cleanliness by changing soiled items promptly; this helps in preventing infections.
- During ileostomy appliance changes, check for undissolved medication, which could indicate improper digestive function.
- Use soap and water for cleaning around the stoma while avoiding alcohol products that may cause skin dryness.
Skin Care and Complications
- Consult healthcare providers for any redness or yeast-related growth around the stoma; antifungal treatments may be necessary.
- Use protective products such as Stomahesive paste to guard the skin around stomas from drainage.
Catheter Care
- Regularly check catheter functionality, ensuring it remains secure and that tubing is not kinked.
- The collecting bag should always be below the bladder to facilitate proper drainage.
- Routinely measure and record the urine volume in the bag, ensuring timely emptying.
Urinary Incontinence and Retention
- Urinary incontinence results in involuntarily leaking urine; urinary retention is defined as the inability to empty the bladder.
- Nursing interventions for urinary retention may include bladder scanning and straight catheterization for effective management.
Urinary Diversions
- Cutaneous diversions involve surgical stomas for urine drainage; clients wear an appliance for continuous collection.
- Continent diversions create a urinary reservoir using intestinal segments, allowing for potential voluntary control.
- Surgical preparation should involve consultations with wound and ostomy nurses for long-term physical and emotional adaptations.
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Description
This quiz covers dietary recommendations and management techniques for nausea and vomiting. It addresses the assessment of vomitus, treatment initiation, and prevention of food contamination. Enhance your understanding of effective approaches to client care in these situations.