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 B

Explanation

A. Hold the medication until the client has his evening meal: Holding the medication for this reason is inappropriate because the issue is the elevated potassium level, not the timing with meals.
B. Inform the provider of the client's potassium level: Correct. A potassium level of 5.8 mEq/L is elevated (hyperkalemia), and the provider should be informed immediately before administering any more potassium.
C. Obtain a prescription to increase the dosage of the medication: Increasing the dosage would be dangerous given the elevated potassium level.
D. Give the medication as prescribed: Administering potassium chloride with a high potassium level is unsafe and could exacerbate the hyperkalemia.

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

A nurse is preparing to administer potassium chloride to a client who has a potassium level of 5.8 mEq/L. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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