The nurse is caring for different 4 clients. Which of the following client assessments would cause the most concern for the nurse?

An 80-year-old who has green liquid stool collecting in the colostomy pouch

An 18-year-old with slight bleeding when wiping the colostomy with a gauze

A 45-year-old with newly placed colostomy on the right which is red and moist

A 55-year-old who has a pale pink/purple, moist colostomy with light brown drainage

Answer and Explanation

The Correct Answer is D

Choice A reason: Green liquid stool in a colostomy pouch is often benign, resulting from diet (e.g., green vegetables) or medications. In an 80-year-old, this is not immediately concerning unless accompanied by systemic symptoms like fever or pain.

Choice B reason: Slight bleeding when wiping a colostomy is common, especially in an 18-year-old with a new stoma, due to fragile tissue. It warrants monitoring but is not as concerning as signs of poor stoma viability.

Choice C reason: A red, moist colostomy in a 45-year-old indicates a healthy, well-perfused stoma, which is normal post-placement. This is an expected finding and does not raise immediate concern compared to abnormal stoma appearance.

Choice D reason: A pale pink/purple colostomy suggests poor perfusion or ischemia, especially in a 55-year-old. This abnormal color, even with moisture, indicates potential stoma necrosis, requiring urgent assessment to prevent complications like tissue death or infection.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Furosemide 60 mg requires 1.5 tablets of 40 mg (60 ÷ 40 = 1.5). Scored tablets allow precise division, ensuring the correct dose. This calculation aligns with safe medication administration principles, delivering the prescribed amount accurately.

Choice B reason: Administering 2.5 tablets (100 mg) exceeds the prescribed 60 mg dose. Overdosing furosemide, a loop diuretic, risks excessive diuresis, leading to dehydration, hypokalemia, or hypotension, making this choice unsafe and incorrect.

Choice C reason: Two tablets (80 mg) also exceed the 60 mg order. This overdose could cause significant fluid and electrolyte imbalances, particularly in vulnerable patients, as furosemide promotes rapid sodium and water excretion, making this choice inappropriate.

Choice D reason: One tablet (40 mg) underdoses the patient, providing only 66.7% of the prescribed 60 mg. Inadequate dosing may fail to achieve therapeutic effects, such as edema reduction or blood pressure control, rendering this choice incorrect.

A. I will wipe from the back to front with the cleansing cloth. B. I should not collect a urine sample when I am menstruating. C. I should let the urine cool to room temperature before sending it to the lab. D. I need to urinate a small amount in the toilet before collecting the sample.

Correct Answer is D

Explanation

Choice A reason: Wiping from back to front risks introducing perianal bacteria into the urethra, contaminating the sample. Proper technique involves wiping front to back to minimize contamination, making this statement incorrect and indicative of misunderstanding.

Choice B reason: While menstruation may complicate urine collection, it is not an absolute contraindication. With proper technique (e.g., using a tampon), samples can be collected. This statement reflects a misconception and does not confirm understanding of midstream collection.

Choice C reason: Urine should be sent to the lab promptly or refrigerated to prevent bacterial growth or analyte degradation. Allowing it to cool to room temperature risks inaccurate results, so this statement demonstrates a lack of understanding of proper handling.

Choice D reason: Urinating a small amount into the toilet first flushes out urethral contaminants, ensuring a cleaner midstream sample. This technique is critical for accurate urinalysis or culture, confirming the client’s understanding of the taught procedure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for different 4 clients. Which of the following client assessments would cause the most concern for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Physician order reads: Furosemide 60 mg po bid. Available: 40 mg scored tablets. What do you administer to the patient?

Correct Answer is A

Explanation

A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient’s blood pressure is 110/60 mmHg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?

A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective?

The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?

A nurse is obtaining a 24-hour urine specimen collection from the patient. Which action should the nurse take?