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The nurse is providing discharge teaching to a client with a new colostomy. Which statement by the client indicates a need for further teaching?
- A. I will avoid foods that cause gas.
- B. I will change my colostomy bag every week.
- C. I will use a skin barrier to protect the skin around the stoma.
- D. I will empty my colostomy bag when it is one-third full.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When assessing the health of a community, what is the most important information for the nurse to obtain?
- A. life expectancy of clients in the community
- B. mortality rates in the community
- C. description of health problems by community leaders
- D. expressed needs of community members
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?
- A. Oxygen saturation of 88%.
- B. Use of accessory muscles for breathing.
- C. Respiratory rate of 26 breaths per minute.
- D. Barrel-shaped chest.
Correct Answer: C
Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.
During a follow-up visit, a client with diabetes reports difficulty maintaining a healthy diet. What should the nurse do first?
- A. provide the client with meal planning resources
- B. explore the client's dietary habits and challenges
- C. refer the client to a nutritionist
- D. educate the client on the importance of a healthy diet
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which annual screening should the nurse include when planning eye health programs at a preschool?
- A. visual acuity
- B. red light reflex
- C. conjunctivitis
- D. glaucoma
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client with Addison's disease. Which finding requires immediate intervention?
- A. Hyperpigmentation of the skin.
- B. Low blood pressure.
- C. Nausea and vomiting.
- D. Hypoglycemia.
Correct Answer: B
Rationale: Low blood pressure in a client with Addison's disease requires immediate intervention as it can indicate an Addisonian crisis, a life-threatening condition that necessitates prompt treatment. Hyperpigmentation of the skin is a characteristic finding in Addison's disease but does not require immediate intervention. Nausea and vomiting can be managed symptomatically in Addison's disease. While hypoglycemia needs attention, it is not the most critical finding requiring immediate intervention in this context.