A nurse is reinforcing teaching with a client who is to take a fecal occult blood test at home. Which of the following instructions should the nurse include in the teaching?

Apply five drops of developer to each smear.

Use the same part of stool for each sample.

Ensure the sample contains no urine.

Wait 10 min before applying the developing solution.

Answer and Explanation

The Correct Answer is C

A. Apply five drops of developer to each smear: Typically, two drops of developer are applied per sample, not five. Applying excess developer may dilute the reaction and yield unreliable results.
B. Use the same part of stool for each sample: Samples should be taken from different parts of the stool to ensure accuracy and detect localized bleeding.
C. Ensure the sample contains no urine: Urine contamination can interfere with test results, leading to inaccurate findings. The client should collect a clean stool sample.
D. Wait 10 min before applying the developing solution: The developing solution should be applied immediately after placing the stool sample on the test card to prevent errors in interpretation.

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Correct Answer is B

Explanation

A. Administer a glycerin suppository: While this may help, addressing bowel hypoactivity through ambulation is less invasive and more appropriate initially.
B. Ambulate the client in the hallway. Ambulation stimulates peristalsis, which can help resolve hypoactive bowel sounds and abdominal discomfort, making it the priority action.
C. Request the client to be NPO: Making the client NPO might be necessary later if symptoms worsen or there is suspicion of ileus or obstruction, but it is not the first action.
D. Offer an analgesic medication: Pain relief is essential, but analgesics (especially opioids) can worsen bowel hypoactivity. Prioritize interventions that restore bowel function first.

A. Empty the pouch when it is 1/3 to 1/2 full. B. Use a standard enema set to irrigate the colostomy. C. Cleanse the skin surrounding the stoma with moisturizing soap. D. Cut the opening in the skin barrier 1/4 inch larger than the stoma.

Correct Answer is A

Explanation

A. Empty the pouch when it is 1/3 to 1/2 full: This prevents the weight of the pouch from causing leaks or pulling on the stoma.
B. Use a standard enema set to irrigate the colostomy: This is incorrect as a standard enema set is not typically used. Colostomy irrigation requires specific equipment and is not performed routinely.
C. Cleanse the skin surrounding the stoma with moisturizing soap: Moisturizing soap can leave a residue that interferes with adhesive barriers. Mild, non-moisturizing soap or just water should be used.
D. Cut the opening in the skin barrier 1/4 inch larger than the stoma: The opening should fit closely to the stoma to protect the surrounding skin from irritation and leakage.

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A nurse is reinforcing teaching with a client who is to take a fecal occult blood test at home. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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