Nokea
The nurse is teaching the client how to care for her ileostomy. The client asks the nurse how long she can wear her pouch before changing it. The nurse responds:
- A. The pouch is changed only when it leaks.
- B. You can wear the pouch for about 4 to 7 days.
- C. You can wear the pouch for about 4 to 7 days.
- D. It depends on your activity level and your diet.
Correct Answer: B
Rationale: An ileostomy pouch is typically worn for 4 to 7 days unless it leaks or causes skin irritation, providing a standard guideline for routine changes. Activity level and diet may influence output but are not the primary determinants for pouch change frequency. CN: Physiological adaptation; CL: Synthesize
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- A. Bananas.
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- C. Apples.
- D. Bread.
Correct Answer: A
Rationale: Bananas are high in potassium, unsuitable for a low-potassium diet.
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- A. Complete symptom reversal.
- B. Maintain functional ability.
- C. Eliminate all medications.
- D. Prevent all complications.
Correct Answer: B
Rationale: Maintaining functional ability is a realistic goal for managing chronic neurological conditions.
A client undergoing a mastectomy asks why she needs to sign a blood transfusion consent form. The nurse's best response is:
- A. œIt's a precaution in case of excessive bleeding during surgery.'
- B. œAll surgical clients must sign this form.'
- C. œIt ensures you receive blood if you request it.'
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Correct Answer: A
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- A. To align injured bones.
- B. To provide long-term pull.
- C. To apply 25 lb of traction.
- D. To pull weight with a boot.
Correct Answer: C
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Which of the following is most effective in assessing the client suspected of developing diabetes insipidus?
- A. Taking vital signs every 2 hours.
- B. Measuring urine output hourly.
- C. Assessing arterial blood gas values every other day.
- D. Checking blood glucose levels.
Correct Answer: B
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