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The nurse is teaching a client how to care for a colostomy. Which factor indicates that the client needs more instruction?
- A. The client says, 'I will change the bag as soon as it gets full.'
- B. The client is observed irrigating the colostomy while sitting on the toilet.
- C. The client positions the irrigating solution container at shoulder level.
- D. The client places a chlorophyll tablet in the drainage bag.
Correct Answer: B
Rationale: Irrigating while sitting on the toilet risks contamination; irrigation should be done in a controlled setting, indicating a need for further instruction.
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The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet?
- A. Vegetables
- B. Cereal
- C. Fruit
- D. Meats
Correct Answer: B
Rationale: Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron.
The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings should the nurse report immediately?
- A. Absence of bowel sounds.
- B. Mild abdominal distension.
- C. Pain at the incision site.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: Absence of bowel sounds on day 2 suggests ileus or obstruction, requiring immediate reporting. Options B, C, and D are expected or normal.
When describing the correct way for cleansing a wound site, the nurse understands that the wound should be cleaned:
- A. From the top to the bottom two times, with the swab discarded
- B. From the outermost region to the center
- C. With circular motions from the drainage site to the outermost edges
- D. With normal saline followed by an astringent wash
Correct Answer: C
Rationale: Cleaning from the drainage site outward prevents spreading pathogens. Other methods risk contamination or are inappropriate.
The nurse is caring for clients in the prenatal clinic. The nurse would be MOST concerned if a diabetic client in the third trimester makes which of the following statements?
- A. I am taking less insulin now than I did two months ago.
- B. I am eating a large bedtime snack.
- C. I walk 15 minutes after lunch every day.
- D. I check my blood sugar two hours after each meal.
Correct Answer: A
Rationale: Decreased insulin needs in the third trimester suggest placental dysfunction, as placental hormones typically increase insulin resistance. Options B, C, and D are appropriate: bedtime snacks prevent hypoglycemia, exercise after meals manages glucose, and postprandial checks monitor hyperglycemia.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about glimepiride (Amaryl). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication before breakfast.
- B. I should report sweating to my doctor.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping glimepiride when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: pre-breakfast dosing maximizes efficacy, sweating indicates hypoglycemia, and alcohol increases hypoglycemia risk.