Nokea
A nurse is reinforcing teaching about ostomy care with a client who has a new colostomy. Which of the following findings should the nurse instruct the client to report to the provider?
- A. Soft, unformed stools
- B. Purplish stoma
- C. Noticeable stool odor
- D. Slight bleeding around the stoma
Correct Answer: B
Rationale: A purplish stoma indicates potential ischemia or poor blood supply, requiring prompt reporting to the provider.
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A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Season foods with spices.
- C. Provide a high-calorie diet.
- D. Administer an antiemetic after each meal.
Correct Answer: C
Rationale: A high-calorie diet addresses malnutrition in AIDS clients, supporting nutritional needs and immune function.
A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?
- A. Perform suctioning.
- B. Instill saline into the tubing.
- C. Increase the humidification.
- D. Check the cuff pressure.
Correct Answer: A
Rationale: Restlessness and crackles in the lungs suggest secretions in the airway, and suctioning is the appropriate intervention to clear them in a client with a tracheostomy.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Monitor the client for weight.
- B. Check the client for increased hypopigmentation under the patch.
- C. Advise the client about increased dry mouth.
- D. Inform the client of the adverse effect of diarrhea.
Correct Answer: C
Rationale: Clonidine can cause dry mouth as a common side effect, and advising the client about this is appropriate for the plan of care.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. It is common for the skin on my breasts to dimple.
- B. I will perform breast exams every other month.
- C. It is common for one breast to be larger than the other.
- D. I will perform breast exams the day my period begins.
Correct Answer: C
Rationale: It is normal for one breast to be slightly larger than the other, reflecting an understanding of breast self-examination teaching.
Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Which of the following actions should the nurse assist with?
- A. Start the prescribed antibiotic
- B. Discontinue nasogastric tube
- C. Reinforce preoperative teaching
- D. Provide the client with ice chips
Correct Answer: C
Rationale: Reinforcing preoperative teaching is appropriate given the potential need for surgery due to suspected bowel obstruction, as indicated by symptoms.