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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 bleeds lightly when touched.
- B. The stoma appears dark in color.
- C. The stoma protrudes slightly from the abdomen.
- D. The stoma is draining a small amount of liquid stool.
Correct Answer: B
Rationale: A dark stoma suggests ischemia or necrosis, requiring urgent reporting.
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A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Use a filter needle to aspirate the medication.
- B. Inject air into the ampule prior to drawing the medication into a syringe.
- C. Cleanse the tip of the ampule with an alcohol swab after opening.
- D. Add 0.5 mL of diluent to the medication.
Correct Answer: A
Rationale: A filter needle prevents glass particles from entering the syringe.
A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Turn off alarms on bedside monitoring equipment
- B. Avoid entering the client's room unless requested during the night.
- C. Conduct staff communications away from the client's room.
- D. Turn on the client's TV to distract from hallway noise.
Correct Answer: C
Rationale: Conducting staff communications away from the client's room reduces noise and promotes a restful environment.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Bear weight on the unaffected leg.
- B. Stand with the crutch tips against the feet.
- C. Hold the arms straight when walking.
- D. Keep the crutches at the level of the axillae.
Correct Answer: A
Rationale: In the three-point gait, weight is borne on the unaffected leg while moving crutches and the affected leg together.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply antiseptic ointment to the tip of my penis.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will clamp the tube when I go for a walk.
Correct Answer: B
Rationale: Keeping the drainage bag below waist level prevents backflow and reduces infection risk.
A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Request the client remain supine for 10 min following administration.
- B. Pull the client's pinna downward and back.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
Correct Answer: C
Rationale: Holding the dropper 1 cm from the ear ensures precise administration without contamination.