A nurse is collecting data from a client who is postoperative following placement of a colostomy in the ascending colon. In which of the following locations should the nurse expect to find the stoma?

Answer and Explanation

The Correct Answer is A

A. Right upper quadrant is correct. A colostomy placed in the ascending colon is typically located in the right upper quadrant of the abdomen. The ascending colon runs along the right side of the abdomen, so the stoma will be located in that region.

B. Left lower quadrant is incorrect. The left lower quadrant is typically where the descending colon or sigmoid colon are located, so a colostomy placed here would be for those regions, not the ascending colon.

C. Left upper quadrant is incorrect. The left upper quadrant contains parts of the stomach, spleen, and pancreas, but not the ascending colon. A colostomy in the ascending colon would not be located here.

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Correct Answer is B

Explanation

A. Erythema is a sign of infection or irritation, not fluid infiltration. Fluid infiltration typically does not cause redness or inflammation.

B. Edema is correct. Fluid infiltration occurs when the IV catheter becomes displaced and the fluid leaks into the surrounding tissue, causing swelling (edema. at the insertion site.

C. Blood would suggest either an accidental dislodging of the catheter or a complication such as hematoma formation, but it is not a sign of fluid infiltration.

D. Pruritus (itching) is typically associated with an allergic reaction, not fluid infiltration.

A. Keep track of how long it takes to complete certain tasks. B. Delegate collection of vital signs to the assistive personnel on the team. C. Make a priority to-do list at the beginning of the shift. D. Plan a time at the end of the shift to document nursing interventions. E. Complete activities with one client before moving to another client.

Correct Answer is ["A","B","C","E"]

Explanation

A. Keep track of how long it takes to complete certain tasks is correct. Tracking the time it takes to complete tasks can help the nurse identify areas for improvement and prioritize tasks accordingly.

B. Delegate collection of vital signs to the assistive personnel on the team is correct. Delegating tasks such as vital sign monitoring to assistive personnel allows the nurse to focus on higher-level clinical duties and improves time management.

C. Make a priority to-do list at the beginning of the shift is correct. Creating a to-do list helps the nurse organize tasks based on urgency, improving overall time management and ensuring critical tasks are addressed.

D. Plan a time at the end of the shift to document nursing interventions is incorrect. Documentation should be done throughout the shift as interventions are performed, not solely at the end. Delaying documentation can lead to errors and missed information.

E. Complete activities with one client before moving to another client is correct. Focusing on one client at a time helps ensure each task is completed thoroughly and reduces the risk of neglecting important care steps.

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A nurse is collecting data from a client who is postoperative following placement of a colostomy in the ascending colon. In which of the following locations should the nurse expect to find the stoma?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?

Correct Answer is B

Explanation

A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

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