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A nurse is reinforcing teaching about ostomy supplies with a client who has a new colostomy. Which of the following information should the nurse include?
- A. Empty the pouch when it is 1/3 to 1/2 full.
- B. Use a standard enema set to irrigate the colostomy.
- C. Cleanse the skin surrounding the stoma with moisturizing soap.
- D. Cut the opening in the skin barrier 1/4 inch larger than the stoma.
Correct Answer: A
Rationale: Emptying the pouch when 1/3 to 1/2 full prevents leakage and maintains skin integrity, a key aspect of ostomy care.
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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.
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
- D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
Correct Answer: C
Rationale: A platelet count of 60,000/mm3 is significantly below the normal range, increasing the risk of bleeding during a liver biopsy, and should be reported to the provider.
A nurse is reinforcing teaching about saturated fats with a client who is at risk for cardiovascular disease. Which of the following cooking fats should the nurse recommend the client use?
- A. Canola oil
- B. Butter
- C. Vegetable shortening
- D. Lard
Correct Answer: A
Rationale: Canola oil is low in saturated fat and heart-healthy, unlike butter, shortening, or lard, reducing cardiovascular risk.
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
- A. Current medication prescriptions
- B. Primary health problem
- C. Number of family members who have visited
- D. Admission vital signs from 1 week ago
- E. Scheduled times for dressing changes
Correct Answer: A,B,E
Rationale: Medications, primary problem, and dressing schedules are critical for continuity of care in the ICU; family visits and old vital signs are less relevant.
A nurse is contributing to the plan of care for a client who has had severe diarrhea for the past 3 days and is now beginning solid foods. Which of the following foods should the nurse include in the plan of care?
- A. Applesauce
- B. Orange slices
- C. Bran cereal
- D. Cottage cheese
Correct Answer: A
Rationale: Applesauce is gentle on the digestive system and helps firm stools, suitable for reintroducing solids after diarrhea.