Nokea
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 protrudes slightly from the abdomen.
- B. The stoma bleeds lightly when touched.
- C. The stoma appears dark in color.
- D. The stoma is draining a small amount of liquid stool.
Correct Answer: C
Rationale: A dark stoma suggests necrosis or ischemia, requiring urgent provider notification.
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A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?
- A. He is here in the hospital, but I cannot tell you anything else.
- B. I cannot confirm or deny that we have a client by that name.
- C. The client's condition is stable right now.
- D. I will tell him you called.
Correct Answer: B
Rationale: Protecting confidentiality under HIPAA requires not confirming client presence.
A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'm glad to have the opportunity to choose what kind of care I receive while I still can.
- B. If I want life support, I'll need to sign a separate consent form first.
- C. I can't change my mind about the care I will receive once I sign my living will.
- D. Once I fill out my living will, there will be a 1-month delay before it is legally binding.
Correct Answer: A
Rationale: Advance directives allow clients to specify care preferences, reflecting autonomy.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Urinate after the specimen collection.
- B. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- C. Keep the specimen in a warm area.
- D. Avoid placing toilet tissue in the bedpan after defecation.
Correct Answer: D
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen.
Nurses' Notes
Vital Signs
Diagnostic Results
6 months ago:
Client present today for annual examination. Reports lack of sleep and increased stress due to moving and starting a new job.
Today, 1400:
Client presents to office today with reports of fatigue. Client states they have difficulty sleeping without drinking four or five beers a night. Client reports, "I sometimes get headaches along with nausea and vomiting. I have been busy with my new job, so I have been eating a lot of fast food, and I've gained 15 pounds."
Today, 1445.
Provider notified of laboratory results.
A nurse is assisting in the care of a client in a provider's office. A nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Administer a diuretic.
- B. Limit alcohol intake to 2 drinks per day.
- C. Keep daily fat intake to less than 35%
- D. Place on 2300 mg sodium diet.
- E. Administer an antibiotic
- F. Limit foods high in potassium.
Correct Answer: A, B, C, D
Rationale: A: Addresses fluid retention from fast food. B, C, D: Manage weight gain and hypertension risks.
A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?
- A. Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field
- B. Opening the top flap of the sterile tray package away from their body
- C. Dropping sterile objects onto the field from a height of 5 cm (2 in)
- D. Placing the cap of a sterile solution on a clean surface with the inside facing down
Correct Answer: B
Rationale: Opening the flap away maintains sterility by keeping the nurse's body out of the field.