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A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma is draining a small amount of liquid stool.
- B. The stoma protrudes slightly from the abdomen.
- C. The stoma appears dark in color.
- D. The stoma bleeds lightly when touched.
Correct Answer: C
Rationale: A dark stoma suggests ischemia or necrosis, requiring urgent reporting.
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A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Using a quick-release tie to secure the restraint.
- B. Tying the restraint to the bed frame.
- C. Placing the restraint across the client's chest.
- D. Applying the restraint over the client's gown.
Correct Answer: C
Rationale: Placing the restraint across the chest restricts breathing and is unsafe, requiring intervention.
A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?
- A. Flex hips and knees when assisting the client to a standing position.
- B. Pivot on the foot farthest from the bed when assisting the client into the chair.
- C. Stand on the client's stronger side when moving the client into the chair.
- D. Raise the bed to waist level before moving the client.
Correct Answer: A
Rationale: Flexing hips and knees uses proper mechanics, reducing injury risk during transfer.
A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. Encourage your partner to eat three large meals each day.
- B. Opioids will be restricted if your partner develops respiratory distress.
- C. We will use an electric blanket to keep your partner warm.
- D. Assume your partner can hear you, even if they do not respond.
Correct Answer: D
Rationale: Hearing may persist, so speaking provides comfort and connection.
A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?
- A. Place an identification tag on the outside of the client's shroud.
- B. Ask the assistive personnel to document the client's time of death.
- C. Wear sterile gloves when cleaning the client's body.
- D. Remove the client's dentures and give them to the client's family.
Correct Answer: A
Rationale: An ID tag ensures proper identification for autopsy purposes.
A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?
- A. Hyperactive bowel sounds are present.
- B. Stomach contents are yellowish green in color.
- C. Aspirated stomach contents' pH measures 6.5.
- D. Residual volume of stomach contents measures 90 mL.
Correct Answer: C
Rationale: A pH of 6.5 suggests possible tube misplacement, requiring immediate reporting.