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The nurse is caring for a client who has just returned from surgery for an ascending colostomy. The nurse plans to include reinforcement teaching for the client and spouse. Which statements should the nurse include in the teaching? Select all that apply.
- A. The colostomy will begin functioning within 24 hours.
- B. A large amount of bleeding may be present at the stoma site.
- C. The first stools will be liquid and will gradually become more formed.
- D. A healthy stoma is reddish-pink and moist and protrudes about 2 cm from the abdominal wall.
Correct Answer: C,D
Rationale: A healthy stoma is reddish-pink, moist, and protrudes slightly (D). Initial stools are liquid, becoming formed over time (C). Function typically starts in 2-5 days, not 24 hours (A), and significant bleeding (B) is abnormal.
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Which task should be assigned to the nursing assistant?
- A. Placing the client in seclusion
- B. Emptying the Foley catheter of the preeclamptic client
- C. Feeding the client with dementia
- D. Ambulating the client with a fractured hip
Correct Answer: C
Rationale: Feeding a client with dementia is within the nursing assistant's scope, as it involves basic care and does not require advanced skills.
A client with cervical cancer has a radioactive implant. Which statement indicates that the client understands the nurse's teaching regarding radioactive implants?
- A. I won't be able to have visitors while getting radiation therapy.
- B. I will have a urinary catheter while the implant is in place.
- C. I can be up to the bedside commode while the implant is in place.
- D. I won't have any side effects from this type of therapy.
Correct Answer: C
Rationale: Clients with radioactive implants can use the bedside commode if the implant remains secure, indicating understanding of mobility restrictions to minimize radiation exposure.
The nurse has an order to administer 100 units of regular insulin in 500 mL of 0.9% NS to infuse at 12 units per hour. The nurse should program the IV pump to deliver how many mLs per hour?
Correct Answer: 60
Rationale: Concentration: 100 units/500 mL = 0.2 units/mL. To deliver 12 units/hour: 12 ÷ 0.2 = 60 mL/hour.
The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:
- A. Mydriatics to facilitate removal
- B. Miotic medications such as Timoptic
- C. A laser to smooth and reshape the lens
- D. Silicone oil injections into the eyeball
Correct Answer: A
Rationale: Mydriatics are used to dilate the pupil, facilitating lens removal during cataract surgery.
The nurse is caring for an infant admitted from the delivery room. Which finding should be reported?
- A. Acyanosis
- B. Acrocyanosis
- C. Halequin sign
- D. Absent femoral pulses
Correct Answer: D
Rationale: Absent femoral pulses suggest coarctation of the aorta, a critical condition.