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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

• Repeat quantitative B-hCG level: Monitoring the trend of quantitative beta-hCG levels is crucial in suspected ectopic pregnancy. Falling or plateauing hCG levels confirm the diagnosis and guide the management plan, especially if methotrexate is administered or surgical intervention is considered.

• Methotrexate IM: Methotrexate is an anticipated prescription for the medical management of a stable ectopic pregnancy. It works by stopping the growth of rapidly dividing cells and is appropriate when the client is hemodynamically stable and the ectopic pregnancy is unruptured.

• Blood typing: Blood typing is essential to determine Rh factor status. If the client is Rh-negative, Rh immune globulin should be administered to prevent isoimmunization, which could impact future pregnancies. This is a standard part of the care plan for any pregnancy loss or threatened pregnancy complication.

• Transvaginal ultrasound: A transvaginal ultrasound is needed to confirm the location of the pregnancy. In ectopic pregnancies, it helps visualize the presence or absence of an intrauterine gestational sac and may directly identify ectopic implantation, such as in the fallopian tube.

• Cervical cerclage: Cervical cerclage is contraindicated in this case. It is used to prevent preterm birth in clients with cervical insufficiency but is not appropriate in a non-viable pregnancy or suspected ectopic pregnancy. Placing a cerclage could worsen the clinical situation and delay necessary treatment.

A. Frequent swallowing B. Report of sore throat C. Dark brown blood between the teeth D. Coffee-ground appearance of emesis

Correct Answer is A

Explanation

A. Frequent swallowing: Frequent swallowing after a tonsillectomy can be a sign of active bleeding from the surgical site. Even if bleeding is not visible, the child may be swallowing blood, which can lead to significant hemorrhage. This is the priority finding that requires immediate intervention.

B. Report of sore throat: A sore throat is an expected and normal finding after a tonsillectomy due to surgical trauma and healing. It does not represent an urgent or life-threatening complication.

C. Dark brown blood between the teeth: Dark brown blood suggests old, minimal bleeding and is not as concerning as active bright red bleeding. While it should be monitored, it is not the priority compared to signs of active hemorrhage.

D. Coffee-ground appearance of emesis: Coffee-ground emesis suggests the presence of digested blood, often from swallowed blood, and while concerning, it is a secondary finding. Frequent swallowing points more directly to active bleeding, which is more immediately life-threatening.

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A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

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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?

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Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

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A nurse is assisting with the care of a client. Select the 4 responsibilities the nurse has in relation to the client's advance directives.