A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following information should the nurse include in the teaching?

"You can expect fecal output within 24 hours."

"You may experience a small amount of bleeding around the stoma."

"You can expect the stoma to be purplish in color for the first week.

"You will need to increase your dietary intake of raw vegetables."

Answer and Explanation

The Correct Answer is B

A. "You can expect fecal output within 24 hours." Fecal output usually occurs within 2-4 days after surgery, not within 24 hours.
B. "You may experience a small amount of bleeding around the stoma." A small amount of bleeding around the stoma is normal, especially right after surgery.
C. "You can expect the stoma to be purplish in color for the first week." A healthy stoma should be pink to red. A purplish color could indicate poor blood supply and should be reported.
D. "You will need to increase your dietary intake of raw vegetables." Raw vegetables can cause gas and obstruction; clients are usually advised to avoid them initially.

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Correct Answer is A

Explanation

A. Urine output 20 mL/hr: Oliguria, or low urine output (less than 30 mL/hr), is a common sign of dehydration.
B. Bradycardia: Dehydration typically causes tachycardia (increased heart rate) as the body compensates for decreased blood volume.
C. Sodium 142 mEq/L: A sodium level of 142 mEq/L is within the normal range (135-145 mEq/L) and does not indicate dehydration.
D. Cool skin: Dehydration usually results in warm, dry skin due to decreased perfusion and sweating.

A. Observe the client. B. Complete an incident report. C. Notify the nurse manager. D. Call the client's provider.

Correct Answer is A

Explanation

A. Observe the client. The first priority is to monitor the client for any adverse reactions or side effects from the wrong medication.
B. Complete an incident report. While important, the incident report is not the first action to take.
C. Notify the nurse manager. Informing the nurse manager is necessary, but not the immediate first step.
D. Call the client's provider. Notifying the provider is also important but observing the client for any immediate effects takes precedence.

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A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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