A nurse is teaching a newly licensed nurse about the function of the large intestine. Which of the following information should the nurse include?
It produces vitamin D.
It absorbs liquid to form stool.
It prevents the reflux of food into the esophagus.
It secretes enzymes to digest food.
The Correct Answer is C
A. The nurse coats the indwelling urinary catheter with lubricant. This is correct procedure and requires no intervention. Lubricating the catheter reduces friction and discomfort during insertion.
B. The nurse applies the sterile drape prior to inserting the urinary catheter. This is correct procedure and requires no intervention. The sterile drape maintains a sterile field.
C. The nurse separates the client's labia with her dominant hand. The nurse should separate the client's labia with her non-dominant hand, which then remains in place as a "dirty" hand. The dominant hand, which remains sterile, is used to insert the catheter.
D. The nurse provides perineal care prior to inserting the urinary catheter. This is correct procedure and requires no intervention. Perineal care reduces the risk of introducing bacteria into the urinary tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Your colostomy will not produce formed stool." A sigmoid colostomy is located in the lower part of the large intestine where stool is typically more formed. Therefore, this statement is incorrect and should not be included in the teaching.
B. "You should expect your stoma to be a purple color." A healthy stoma should be pink or red and moist. A purple, dusky, or dark color may indicate compromised blood flow to the stoma and is a sign of a medical emergency. This statement is incorrect.
C. "The end of the stoma will be painful after this procedure." The stoma itself does not have nerve endings, so it should not be painful. Pain around the incision site may occur, but the stoma itself should not be painful. This statement is incorrect.
D. "You will have a stoma in your left lower abdomen." The sigmoid colon is located on the lower left side of the abdomen, so the stoma for a sigmoid colostomy is typically placed in this area. This statement is correct.
Correct Answer is C
Explanation
A. Lactulose: Lactulose is used to reduce blood ammonia levels in hepatic encephalopathy, not to reduce potassium levels. It is not appropriate for treating hyperkalemia.
B. Sevelamer: Sevelamer is a phosphate binder used in clients with chronic kidney disease to lower serum phosphorus levels, not potassium. It is not appropriate for treating hyperkalemia.
C. Sodium polystyrene: Sodium polystyrene (Kayexalate) is a cation-exchange resin used to treat hyperkalemia. It works by exchanging sodium ions for potassium ions in the intestine, promoting the excretion of potassium. This is the correct medication to administer for a serum potassium level of 6.8 mEq/L.
D. Darbepoetin alfa: Darbepoetin alfa is a synthetic erythropoietin used to treat anemia associated with chronic kidney disease. It is not used to treat hyperkalemia.
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