A nurse is reinforcing teaching for a client who has a new sigmoid colostomy. Which of the following comments by the client indicates an understanding of the teaching?

“I will empty the pouch every 2 to 3 hours."

“I will no longer be able to eat nuts."

“I should expect my stool to be unformed."

"I will notify my doctor if the stoma starts to look purple."

Answer and Explanation

The Correct Answer is D

A. "I will empty the pouch every 2 to 3 hours.": While it is important to empty the pouch when it is about one-third to half full, emptying it every 2 to 3 hours is unnecessary unless output is extremely high. Frequent emptying is based on the volume of stool, not strict timing.

B. "I will no longer be able to eat nuts.": Clients with a sigmoid colostomy typically resume a normal diet after healing, including nuts, unless otherwise instructed. Nuts are more commonly restricted after ileostomies due to the risk of obstruction, not sigmoid colostomies.

C. "I should expect my stool to be unformed.": Stool from a sigmoid colostomy is usually formed or semi-formed because it comes from the end of the colon where water absorption has mostly occurred. Unformed stool is more characteristic of ileostomies.

D. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should appear pink to red and moist. A purple, dark, or dusky stoma indicates impaired blood flow or ischemia and requires immediate medical evaluation to prevent serious complications.

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Correct Answer is A

Explanation

A. Inject 15 units of air into the regular insulin vial: After injecting air into the NPH vial without drawing up the medication, the next step is to inject air into the regular insulin vial. This maintains the correct order and prevents contamination of the regular insulin with the cloudy NPH insulin.

B. Withdraw 10 units of NPH insulin: NPH insulin should not be withdrawn first because it is cloudy and could contaminate the regular insulin if mixed incorrectly. Regular insulin, which is clear, should always be drawn up before NPH when mixing in the same syringe.

C. Verify the dosage with another nurse: Verifying insulin doses with another nurse is necessary but is typically done after the insulin is prepared and drawn up. At this stage, the immediate step is to complete proper air injection into both vials before drawing any insulin.

D. Place the cap over the needle: Recapping needles increases the risk of accidental needlestick injuries and should be avoided unless absolutely necessary. There is no need to recap at this stage in the insulin preparation process.

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL) B. A client who has a spinal cord injury and needs a dressing change C. A client who has a temperature of 38.4° C (101.1 F) and appears confused D. A client who had a hip arthroplasty and is requesting pain medication

Correct Answer is C

Explanation

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL): A mildly elevated blood glucose level is not immediately life-threatening and can be managed after addressing more urgent issues. This client is stable at the moment.

B. A client who has a spinal cord injury and needs a dressing change: While important for preventing infection, a scheduled dressing change is not an immediate threat to the client’s life or health and can be safely performed after more urgent concerns are addressed.

C. A client who has a temperature of 38.4° C (101.1° F) and appears confused: Fever and new-onset confusion suggest a possible infection, such as sepsis or urinary tract infection, especially in older adults. This situation indicates a potential life-threatening condition and requires immediate assessment and intervention.

D. A client who had a hip arthroplasty and is requesting pain medication: Managing pain is important, but it is not immediately life-threatening. After addressing the client with fever and confusion, attending to the client's pain needs would be appropriate.

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A nurse is reinforcing teaching for a client who has a new sigmoid colostomy. Which of the following comments by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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