NCLEX-PN

Chapter 5: Quiz & Answer Key 1.​ Which of the following is a commonality that is shared in terms of both restraints and urinary catheters? A.​ Both can lead to infection

B.​ Both are invasive procedures C.​ Both are considered sentinel D.​ Both are the last resort

Correct Response : D Explanation : The commonality that is shared in terms of both restraints and urinary catheters is that both are the last, not the first, treatment of choice. Both indwelling urinary catheters and restraints pose risks and complications; therefore, both of these interventions must be prevented with the use of preventive measures. Indwelling urinary catheters are invasive, but restraints are not. Indwelling urinary catheters can lead to infection, but restraints do not. Lastly, neither is sentinel. A sentinel event is an event, occurrence, incident, or accident that has led to or may have possibly led to Client harm. Even near misses that have the potential for harm are considered sentinel events because they have the potential to cause harm in the future. (See Managing Urinary Retention ) 2.​ You are planning discharge education for your client, who has a new colostomy. Which complication of a colostomy should you educate this client about? A.​ A prolapsed stoma B.​ A vitamin B12 deficiency Correct Response : A Explanation : Some of the complications associated with a colostomy include a prolapsed stoma, infection, dehiscence, an ischemic ileostomy, a parastomal hernia, stoma stenosis, stomal retraction, necrosis, mucocutaneous separation, stomal trauma, peristomal skin damage as the result of leakage, and parastomal hernias. A vitamin B12 deficiency, nocturnal enuresis, and urinary stone formations are complications associated with urinary diversion and not fecal ostomy diversions. (See Enemas and Fecal Diversion in Healthcare ) 3.​ Your incontinent client is incontinent of urine and stool. Which of the following products would you recommend for this Client when cost is a major consideration in this decision? A.​ Any solid skin barrier B.​ A hydrocolloid solid skin barrier C.​ Hollister’s Flextend D.​ A skin sealant Correct Response : D C.​ Nocturnal enuresis D.​ GI stone formation

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