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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wear sterile gloves when withdrawing the medication from the ampule: Sterile gloves are not necessary; clean gloves are sufficient.
B. Shake the ampule to move the solution below the neck: Shaking the ampule can cause the solution to spill. Tapping the ampule gently is recommended.
C. Snap the top of the ampule towards hands: Snapping the top towards hands can result in injury. The ampule should be snapped away from the hands.
D. Use a filter needle to draw up the medication: A filter needle prevents glass particles from being drawn up into the syringe.
Correct Answer is A
Explanation
A. Temporary urinary retention: After removal of an indwelling catheter, especially in older adults, temporary urinary retention can occur due to decreased bladder tone or urethral irritation.
B. Blood-tinged urine: This is not an expected outcome; it could indicate trauma or infection and should be evaluated.
C. Urinary frequency for several days: While increased frequency might occur immediately after catheter removal, it is not typically expected to last for several days.
D. Highly concentrated urine: Urine concentration would depend on the client's hydration status rather than the removal of the catheter.
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