Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

Urinary output.

Serum electrolytes.

Peristomal skin integrity.

Skin turgor.

Answer and Explanation

The Correct Answer is B

A.   While monitoring urinary output is important, it is not the most critical assessment in this context.
B.   Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C.   Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D.   Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.

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Correct Answer is ["B","H"]

Explanation

A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.

B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.

E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.

H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

A. Tell the child he will have to have a shot instead. B. Hide the medication in a large dish of ice cream. C. Tell the child it is candy. D. Offer the child a choice of taking the medication with juice or water.

Correct Answer is D

Explanation

A. Threatening the child with a shot may create anxiety and fear, making cooperation even more challenging.
B. Hiding medication in food without the child's knowledge can lead to mistrust and may not be safe, as the child may not consume the entire dose.
C. Misleading the child about the nature of the medication is not appropriate. It can lead to confusion and mistrust when the child realizes that it is not candy.

D. Providing choices empowers the child and makes the process of taking medication less intimidating. It also helps in engaging the child in their own care, making them feel more in control.

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Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

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Naxlex Comprehensive Predictor Exams

What 2 orders should the nurse complete first?

Correct Answer is ["B","H"]

Explanation

A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation?

Correct Answer is D

Explanation

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?

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The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?