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 ["A","B","C"]

Explanation

A. Placing the client in high Fowler's position helps improve lung expansion and oxygenation.
B. Administering oxygen helps address hypoxia and supports adequate oxygenation.
C. Stopping the transfusion is crucial when signs of a transfusion reaction are present.
D. Administering a diuretic is not typically indicated for transfusion reactions involving lung crackles, hypoxia, and distended neck veins.
E. Epinephrine is not typically used to manage a blood transfusion reaction; it's more for severe allergic reactions like anaphylaxis.

A. Assist the client into semi-Fowler's position. B. Give the client's medications between meals. C. Encourage the client to use a straw to take the medications. D. Administer the client's medications one at a time.

Correct Answer is D

Explanation

A. Assisting the client into a semi-Fowler's position might be beneficial but doesn't directly address dysphagia while taking medications.
B. Timing medications between meals isn't directly related to improving medication intake for someone with dysphagia.
C. Using a straw might not be recommended as it could increase the risk of aspiration.
D. Administering medications one at a time allows for better control and observation of swallowing ability and reduces the risk of aspiration.

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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 assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

A nurse is caring for a client who has dysphagia and is receiving oral medications. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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