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 appears dark in color.
- C. The stoma bleeds lightly when touched.
- D. The stoma is draining a small amount of liquid stool.
Correct Answer: B
Rationale: A dark-colored stoma indicates potential ischemia or necrosis, requiring immediate reporting.
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A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Provide oral care to the client once every 8 hr.
- B. Reposition the client once every 4 hr.
- C. Place the head of the client's bed flat.
- D. Use a fan to circulate air in the client's room.
Correct Answer: B
Rationale: Repositioning helps relieve dyspnea by improving lung expansion and comfort.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- B. The sterile solution is poured with the bottle held over the field.
- C. Unnecessary sterile items are placed on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: B
Rationale: Pouring over the field risks contamination from the bottle.
A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?
- A. Soak the hearing aid in warm water.
- B. Decrease the volume on the hearing aid.
- C. Clean the hearing aid with isopropyl alcohol.
- D. Turn the hearing aid off for 5 min.
Correct Answer: B
Rationale: Whistling (feedback) often indicates high volume; decreasing it resolves the issue.
Provider’s Prescriptions
Nurses' Notes
Medical History
Day 1, 1030:
Amoxicillin 500 mg PO every 8 hr Metoprolol 50 mg PO daily
Urine culture and sensitivity
Day 3, 1700:
Metronidazole 250 mg PO three times daily
Obtain stool culture and sensitivity to test for Clostridium difficile.
A nurse is assisting in the care of a client who has a urinary tract infection.
The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.
- A. Recommend increasing the dose of metoprolol
- B. Clarify the prescription for amoxicillin with the provider.
- C. Ensure the client wears a surgical mask when they are outside their room.
- D. Request a prescription for an antiemetic medication
- E. Place the client on contact precautions.
Correct Answer: B, D
Rationale: B: The nurse should clarify the amoxicillin prescription if there's any ambiguity in dosage or administration. D: An antiemetic may be needed if the client experiences nausea from antibiotics or infection.
A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?
- A. Bowling
- B. Jogging
- C. Passive range-of-motion exercise
- D. Walking
Correct Answer: D
Rationale: Walking is weight-bearing and safe, promoting bone health.