An older client with colorectal carcinoma receives a colostomy following a bowel resection and the nurse is reviewing written instructions about colostomy care that the client will take home after discharge. Which action should the nurse include when reviewing the instructions with the client?

Use background music to promote relaxation.

Turn on overhead lights while reviewing instructions.

Stand behind the client to avoid intimidation.

Provide handouts written at a 12th grade reading level.

Answer and Explanation

The Correct Answer is D

A.   While music can be relaxing, it may also be distracting and make it difficult for the client to focus on the instructions.
B.   Bright overhead lights can be uncomfortable and may even cause strain on the eyes. It's generally better to use soft, natural lighting when reviewing instructions.
C.   Standing behind the client can make them feel intimidated or uncomfortable, especially if they are already feeling anxious or overwhelmed. It's better to stand in front of the client and maintain eye contact to show that you are engaged and attentive.
D.   Older adults may have difficulty understanding written information that is too complex. Providing handouts written at a 12th grade reading level ensures that the client can easily comprehend the instructions and follow them at home.

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Correct Answer is B

Explanation

A. Measuring body temperature is important in assessing the client’s overall condition and identifying a fever, which is common in pneumonia. However, while it provides useful information about the client's status, it is not the most urgent action compared to interventions that could immediately impact the client’s respiratory function or confirm the diagnosis.
B. Administering PRN (as needed) oxygen is crucial if the client shows signs of hypoxia or difficulty breathing. If the client's face appears cyanotic or if they are experiencing respiratory distress, this action should be prioritized to ensure adequate oxygenation.
C. A chest x-ray is essential for diagnosing pneumonia and assessing the extent of lung involvement. However, while it is critical for diagnosis, addressing immediate respiratory needs and symptoms takes precedence.
D. Obtaining sputum for culture is important for identifying the causative organism and guiding antibiotic therapy. However, this action is less urgent than ensuring the client’s immediate respiratory needs are met and confirming the diagnosis through imaging.

A. A hemoglobin (Hgb) of 11.8 g/dL (118 g/L) and hematocrit (Hct) of 34% (0.34). B. Low weight as determined from a height/weight comparison chart. C. Decreased lean body mass compared to results of 10 years ago. D. Serum albumin of 3 g/dL (30 g/L) and serum transferrin of 180 mg/dL (1.8 g/L).

Correct Answer is D

Explanation

A. Hemoglobin (Hgb) and Hematocrit (Hct) are important indicators of anemia, which can be caused by nutritional deficiencies such as iron, vitamin B12, or folate deficiencies. For an older adult female, the reference range for hemoglobin is 12 to 16 g/dL, and the hematocrit range is 37% to 47%. A hemoglobin of 11.8 g/dL and a hematocrit of 34% are below the normal range, indicating potential anemia, which could be related to nutritional deficiencies.
B. Weight loss or being underweight can be a sign of nutritional deficiency, particularly if it is unintentional. However, this option lacks specific details about the extent of weight loss and its relation to other indicators. Weight alone does not provide complete information about nutritional deficiencies without additional context, such as changes in weight over time or body composition.
C. A decrease in lean body mass can be indicative of malnutrition or a prolonged deficiency in protein or overall caloric intake. While it is an important indicator of nutritional status, it reflects long-term changes and may not immediately show acute deficiencies.
D. Serum albumin and serum transferrin are biomarkers of nutritional status. The reference range for serum albumin is 3.5 to 5.0 g/dL, and for serum transferrin, it is 250 to 380 mg/dL. A serum albumin level of 3 g/dL and a serum transferrin level of 180 mg/dL are both below the normal range, indicating possible malnutrition or protein deficiency.

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An older client with colorectal carcinoma receives a colostomy following a bowel resection and the nurse is reviewing written instructions about colostomy care that the client will take home after discharge. Which action should the nurse include when reviewing the instructions with the client?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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