Nokea
The nurse is assessing a post operative client who underwent a colostomy, which of the following findings will warrant further nursing interventions?
- A. The stoma appears pale and dry
- B. The stoma appears red
- C. The stoma drains a bloody drainage then progressed to greenish discharge
- D. The stoma drains a greenish discharge
Correct Answer: A
Rationale: A pale, dry stoma e.g., ischemia needs intervention (e.g., notify MD), unlike red (healthy), bloody-to-green (normal), or green (expected). Nurses assess e.g., color for complications, per ostomy care.
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A client with diverticulitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of high-fiber foods.
- B. I should decrease my intake of high-fiber foods.
- C. I should increase my intake of high-fat foods.
- D. I should decrease my intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A. Increasing intake of high-fiber foods is essential in managing diverticulitis as it helps prevent constipation and promotes bowel regularity, reducing the risk of complications and improving overall colon health. Choice B is incorrect because decreasing high-fiber foods can worsen diverticulitis symptoms. Choices C and D are also incorrect as increasing high-fat foods can exacerbate diverticulitis, while decreasing high-fat foods is generally recommended to manage the condition.
Among the following statements, which should be given the HIGHEST priority?
- A. Client is in extreme pain
- B. Client's blood pressure is 60/40
- C. Client's temperature is 40 deg. Centigrade
- D. Client is cyanotic
Correct Answer: B
Rationale: BP 60/40 (B) is highest priority; severe hypotension threatens perfusion, per ABCs (circulation). Pain (A), fever (C), and cyanosis (D) are urgent but secondary to life-threatening shock. B demands immediate action, making it correct.
A healthcare professional is planning care for a client who has a new prescription for a low-sodium diet. Which of the following foods should the healthcare professional recommend?
- A. Canned soup
- B. Fresh fruit
- C. Pickles
- D. Soy sauce
Correct Answer: B
Rationale: Fresh fruit is naturally low in sodium and is a suitable choice for a low-sodium diet. It provides essential nutrients without adding significant amounts of sodium, making it a healthy option for individuals following a low-sodium diet. Canned soup, pickles, and soy sauce are high in sodium content and should be avoided by individuals on a low-sodium diet. Canned soups are often loaded with added salt, pickles are preserved in brine containing high sodium levels, and soy sauce is a condiment with a high sodium content.
A healthcare provider is caring for a client who is receiving IV therapy via a peripheral catheter. The healthcare provider should identify that which of the following findings is an indication of infiltration?
- A. Redness at the infusion site
- B. Edema at the infusion site
- C. Warmth at the infusion site
- D. Oozing of blood at the infusion site
Correct Answer: B
Rationale: Edema at the infusion site is an indication of infiltration, where fluid leaks into the surrounding tissues causing swelling. This can compromise the delivery of medication and fluids, potentially leading to complications. Redness, warmth, and oozing of blood are more suggestive of inflammation or infection rather than infiltration. Infiltration requires prompt recognition and intervention to prevent further issues with the IV therapy.
When administering an IM injection to a 5-month-old infant, which of the following injection sites should be used?
- A. Deltoid
- B. Ventrogluteal
- C. Vastus lateralis
- D. Dorsogluteal
Correct Answer: C
Rationale: For infants and young children, the vastus lateralis muscle located over the anterior thigh is the preferred site for intramuscular injections. This site is chosen for its large muscle mass and reduced risk of injury to major nerves and blood vessels. Infants have less developed muscle structures, making the vastus lateralis a safer and more effective site for injections compared to other sites like the deltoid, ventrogluteal, or dorsogluteal. Using the correct injection site is essential to prevent complications and ensure the proper absorption of the medication.