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 is draining a small amount of liquid stool.
- B. The stoma protrudes slightly from the abdomen.
- C. The stoma bleeds lightly when touched.
- D. The stoma appears dark in color.
Correct Answer: D
Rationale: A dark stoma indicates potential necrosis or ischemia, requiring immediate provider attention.
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A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Family history of osteoporosis
- B. Type 1 diabetes mellitus
- C. Orthostatic hypotension
- D. BMI of 24
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia affecting blood vessels.
A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Assess the pain level of a client who has received acetaminophen.
- B. Measure the intake and output of a client who has received furosemide.
- C. Check a client's peripheral IV site for redness or swelling.
- D. Reinforce teaching with a client about crutch-gait walking.
Correct Answer: B
Rationale: Measuring intake and output is within the AP's scope; assessment and teaching are nurse responsibilities.
A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Request that someone from the client's family participate in the care.
- B. Ask the client to explain her feelings.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: B
Rationale: Exploring feelings addresses emotional barriers, promoting eventual acceptance of care.
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. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- B. Keep the specimen in a warm area.
- C. Avoid placing toilet tissue in the bedpan after defecation.
- D. Urinate after the specimen collection.
Correct Answer: C
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen with fibers or chemicals.
A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?
- A. Rapid chewing
- B. Garbled voice
- C. Sneezing
- D. Increased hunger
Correct Answer: B
Rationale: A garbled voice post-stroke indicates swallowing difficulty, a dysphagia sign.