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. Potassium 2.5 mEq/L: Hypokalemia is a critical finding that can cause severe cardiac and muscular complications, making it the priority.
B. Sodium 142 mEq/L: This sodium level is within the normal range (135-145 mEq/L) and does not indicate an immediate threat.
C. Urine specific gravity 1.025: This specific gravity indicates concentrated urine, which is expected in dehydration, but it is not the most critical finding.
D. Blood glucose 110 mg/dL: This blood glucose level is within the normal range and does not indicate an immediate threat.
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