A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?

Rub the peristomal skin dry after cleaning.

Change the pouch once every 24 hr.

Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.

Apply the pouch while the skin barrier is still damp.

Answer and Explanation

The Correct Answer is C

A.   Rather than rubbing dry, patting the peristomal skin dry after cleaning is recommended.
B.   The frequency of changing the pouch depends on various factors, not a fixed 24-hour schedule.
C.   Ensuring the pouch is slightly larger than the stoma prevents irritation and damage.
D.   Applying the pouch when the skin barrier is dry ensures better adhesion.

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Correct Answer is C

Explanation

A. Cooked vegetables are not typically included in a full liquid diet as they contain solid parts.
B. Bananas are not part of a full liquid diet because they are solid foods.
C. Pudding is a suitable selection for a full liquid diet as it's a smooth, creamy food that's easy to swallow.
D. Yogurt with fruit might contain solid parts, which aren't recommended in a full liquid diet.

A. Heart rate B. Blood pressure C. Temperature D. Urticaria E. Swollen tongue F. Breath sounds

Correct Answer is ["B","D","E","F"]

Explanation

A. While elevated (104/min), it's essential, but not as critical as other findings.
B. The significant drop in blood pressure from 108/56 mm Hg to 88/56 mm Hg within 30 minutes is a cause for immediate concern.
C. The slight increase in temperature (from 37.6°C to 37.5°C) is important but not the most pressing concern.
D. Itching over the chest with urticaria (hives) suggests an allergic reaction, requiring urgent attention.
E. Swelling of the tongue is a severe sign of an allergic reaction and requires immediate intervention.
F. Clear and present breath sounds with scattered wheezing indicate potential airway compromise, requiring immediate follow-up.

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A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

Correct Answer is ["B","D","E","F"]

Explanation

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