The nurse is providing patient education for a client who is going to have an ostomy created due to chronic Crohn's disease. The nurse has decided that pre- operative education is successful when the client states:. (select all that apply).

There will be blood and mucus initially exiting the stoma.

The stoma will shrink a bit over a period of weeks.

The stool will be of normal consistency and color.

The stoma should be beefy red.

Drainage will begin approximately 24-48 hours following surgery.

Answer and Explanation

Correct Answer : A,B,D,E

Pre-operative education is successful when the client states that there will be blood and mucus initially exiting the stoma, the stoma will shrink a bit over a period of weeks, the stoma should be beefy red, and drainage will begin approximately 24-48 hours following surgery. These statements indicate that the client has a good understanding of what to expect after surgery.

Option C, The stool will be of normal consistency and color, is not a correct answer as the stool from an ostomy is different from normal stool consistency and color.

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Correct Answer is B

Explanation

Provide the client with warm fluids. The shivering can occur due to the anesthesia, the effect of the surgery, or cold temperature in the operating room. The shivering increases the client's oxygen consumption and carbon dioxide production, which can cause hypoxia, hypercapnia, and acidosis. The nurse should provide warm fluids to prevent hypothermia and warm blankets to reduce shivering.

Option A, placing the client on a hypothermia blanket, is incorrect because it is used to lower body temperature, not raise it.

Option C, covering the client with a light blanket, is incorrect because it is not enough to keep the client warm.

Option D, ensuring that the room temperature is below 70°F, is incorrect because it is too cold for the client and can increase shivering.

A. Fluid accumulation under the arm. B. Drainage from the area. C. Reddened area around the breast. D. Enlargement of the arm or hand.

Correct Answer is A

Explanation

Fluid accumulation under the arm. The presence of fluid accumulation (edema) under the arm may indicate the spread of breast cancer to the lymph nodes. The physician should be notified, and further evaluation and treatment may be necessary.

Option B: Drainage from the area is not a correct answer as it may indicate a surgical site infection or an abscess, but not necessarily the spread of cancer.

Option C: Reddened area around the breast is not a correct answer as it may indicate a skin infection or inflammation, but not necessarily the spread of cancer.

Option D: Enlargement of the arm or hand is not a correct answer as it may indicate lymphedema, which is a swelling due to lymphatic system damage, but not necessarily the spread of cancer.

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The nurse is providing patient education for a client who is going to have an ostomy created due to chronic Crohn's disease. The nurse has decided that pre- operative education is successful when the client states:. (select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following interventions would be appropriate for a client who has undergone surgery for a liver disorder and has started shivering?

Correct Answer is B

Explanation

The nurse is caring for a client with breast cancer. On evaluation of axillary findings, a potential sign of cancer spread is documented and brought to the physician's attention. Which finding is documented?

Correct Answer is A

Explanation

Which type of sexually transmitted infection is the nurse most accurate to highlight in the client's history as it remains dormant in the body and can recur at any time?

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