Nokea
A nurse is caring for a client who is postoperative following the placement of a colostomy. Which of the following findings indicates the colostomy is functioning properly?
- A. Passing of flatus
- B. Stoma is pinkish-red
- C. Tolerating a clear liquid diet
- D. Absent bowel sounds
Correct Answer: A
Rationale: Passing flatus indicates the colostomy is functioning by expelling gas, a normal postoperative sign. Pink stoma and diet tolerance are positive but not definitive, and absent sounds suggest ileus.
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A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Replace the unit when the drainage chamber is full.
- B. Clamp the tube for 30 min every 8 hr.
- C. Pin the tubing to the client's bed sheets.
- D. Monitor for at least 150 mL of drainage every hour.
Correct Answer: A
Rationale: Replacing the unit when full maintains system function. Clamping risks tension pneumothorax, pinning can dislodge tubing, and 150 mL/hr is excessive and not a standard expectation.
A nurse is caring for a client who has cardiomyopathy and is experiencing sensory overload. Which of the following actions should the nurse take?
- A. Ensure the blinds in the client's room remain open.
- B. Place the client in a room near the nurses' station.
- C. Play quiet music in the client's room.
- D. Break up nursing care into small, frequent sessions.
Correct Answer: D
Rationale: Breaking care into small, frequent sessions reduces sensory overload by minimizing stimulation. Open blinds, proximity to the station, and music could worsen overload in cardiomyopathy.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform breast exams every other month.
- B. It is common for the skin on my breasts to dimple.
- C. I will perform breast exams the day my period begins.
- D. It is common for one breast to be larger than the other.
- E. I'll only check if I feel pain.
- F. I'll use lotion to make it easier.
- G. I'll skip exams after age 40.
Correct Answer: D
Rationale: Asymmetry in breast size is normal; exams should be monthly, post-period, and dimpling is a concern.
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
- A. Assist the client to the restroom 30 min after meals.
- B. Limit the client's physical activity until bowel continence is achieved.
- C. Limit the client's fluid intake to 1500 mL/day.
- D. Instruct the client to limit their intake of high-fiber foods
Correct Answer: A
Rationale: Assisting to the restroom 30 minutes after meals leverages the gastrocolic reflex to promote bowel regularity. Limiting activity, fluids, or fiber would hinder continence efforts.
A nurse is reinforcing teaching with a client who is scheduled to undergo a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?
- A. I can have clear liquids up to 3 hours before the procedure.
- B. I can eat as soon as the procedure is completed.
- C. I will receive an injection of radioactive material prior to having the procedure.
- D. I might have blood-tinged sputum after the procedure.
Correct Answer: D
Rationale: Blood-tinged sputum is normal post-bronchoscopy due to airway irritation, showing understanding. Clear liquids stop earlier, eating waits until gag reflex returns, and no radiation is involved.