A client diagnosed with ulcerative colitis is scheduled for a terminal ileostomy.
The nurse is aware the stoma will be in what area of the client's abdomen?
Right lower quadrant.
Left lower quadrant.
Right upper quadrant.
Left upper quadrant.
The Correct Answer is A
Choice A rationale
A terminal ileostomy involves creating an opening in the right lower quadrant of the abdomen where the ileum is brought to the surface to form a stoma for waste elimination.
Choice B rationale
The left lower quadrant is not used for a terminal ileostomy, as it is not anatomically appropriate for the ileum.
Choice C rationale
The right upper quadrant is not relevant to a terminal ileostomy because the ileum is located in the lower part of the abdomen.
Choice D rationale
The left upper quadrant is also inappropriate for a terminal ileostomy due to the anatomical position of the ileum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A complete blood count (CBC) can provide general information about the body's response to an MI, such as white blood cell count, but it is not definitive for diagnosing an MI.
Choice B rationale
A lipid profile measures cholesterol levels and helps assess cardiovascular risk, but it is not useful for diagnosing an acute MI.
Choice C rationale
An electrocardiogram (ECG) is essential for diagnosing an MI as it shows the heart's electrical activity and can indicate ischemia or infarction.
Choice D rationale
Troponin levels are the most specific and sensitive markers for myocardial infarction. Elevated troponin levels confirm heart muscle damage due to an MI, making it the definitive test.
Correct Answer is C
Explanation
Choice C rationale
Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.
Choice A rationale
Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.
Choice B rationale
Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.
Choice D rationale
Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.
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