A nurse is educating a patient who recently had a colostomy. What information should the nurse include in the teaching?

The stoma may appear purplish during the first week.

A small amount of bleeding around the stoma is normal.

Fecal output can be expected within 24 hours.

An increase in the intake of raw vegetables is necessary.

Answer and Explanation

The Correct Answer is B

Choice A rationale

A stoma may appear red and moist immediately after surgery, similar to the inside of the mouth. A purplish color could indicate a lack of blood supply to the stoma, which is a medical emergency.

Choice B rationale

A small amount of bleeding around the stoma is normal, especially when cleaning the area or changing the ostomy appliance. This is because the stoma contains blood vessels and has a rich blood supply.

Choice C rationale

Fecal output from a colostomy can be expected within 2 to 4 days after surgery. It is not typical to see output within 24 hours.

Choice D rationale

An increase in the intake of raw vegetables is not necessary after a colostomy. In fact, some people may find certain raw vegetables difficult to digest and they may cause gas or odor.

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Correct Answer is D

Explanation

Choice A rationale

Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.

Choice B rationale

Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice C rationale

Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale

Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

A. Don sterile gloves before inserting the indwelling urinary catheter. B. Apply an oil-based lubricant to the indwelling urinary catheter. C. Use one cotton swab to clean the client’s genitalia. D. Test the balloon on the indwelling urinary catheter before insertion.

Correct Answer is A

Explanation

Choice A rationale

Donning sterile gloves before inserting the indwelling urinary catheter is a critical step to prevent infection. The urinary tract is normally sterile, and using sterile gloves helps maintain this sterility during the procedure.

Choice B rationale

Applying an oil-based lubricant to the indwelling urinary catheter is not recommended. Oil- based lubricants can damage latex catheters and increase the risk of infection. A water-soluble lubricant is typically used.

Choice C rationale

Using one cotton swab to clean the client’s genitalia is not sufficient. Proper cleaning and disinfection of the area are crucial to prevent introducing bacteria into the urinary tract during catheter insertion.

Choice D rationale

Testing the balloon on the indwelling urinary catheter before insertion is not typically done. The balloon is usually inflated with sterile water once the catheter is in place to ensure that it remains in the bladder.

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A nurse is educating a patient who recently had a colostomy. What information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with a skin condition. Which of the following describes the client’s condition?

Correct Answer is D

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is about to replace a nearly depleted container of total parenteral nutrition (TPN) for a patient, but discovers a delay in the delivery of the new TPN solution from the pharmacy. Which solution should the nurse administer until the next TPN solution is available?

A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?

A nurse is developing a care plan for a patient with a decreased level of consciousness who is receiving continuous enteral feedings through a gastrostomy tube due to an inability to swallow.What should be the nurse’s priority action?

What should a nurse include in a nutrition class for pregnant teenagers? Choose all that apply.

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

A nurse is caring for a patient who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions?

A nurse is assessing a client who has a colostomy and notices that the stoma is pale in color. Which of the following findings should the nurse report to the provider?

A nurse is preparing to instill 840 mL of enteral nutrition via a patient’s gastrostomy tube over 24 hours using an infusion pump. How many mL/hr should the nurse set the infusion pump to deliver?