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Free NCLEX-RN Exam Braindumps (page: 165)

Page 165 of 431
PDF with 862 Questions

A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:

  1. "I know that I am not supposed to irrigate my colostomy."
  2. "My stool will be soft like paste."
  3. "My stoma should be red and slightly raised."
  4. "The skin around my stoma may become irritated from the enzymes in my stool."

Answer(s): C

Explanation:

(A) A left colostomy indicates an ascending colon resection. This type of colostomy can be irrigated. (B) The stool from an ascending colon resection should be formed. (C) The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately. (D) The stool in the ascending colon does not usually have many enzymes in it. Stool from an ileostomy has more enzymes and is more irritating to the skin.



A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:

  1. "I know that I am not supposed to irrigate my colostomy."
  2. "My stool will be soft like paste."
  3. "My stoma should be red and slightly raised."
  4. "The skin around my stoma may become irritated from the enzymes in my stool."

Answer(s): C

Explanation:

(A) A left colostomy indicates an ascending colon resection. This type of colostomy can be irrigated. (B) The stool from an ascending colon resection should be formed. (C) The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately. (D) The stool in the ascending colon does not usually have many enzymes in it. Stool from an ileostomy has more enzymes and is more irritating to the skin.



The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:

  1. Prolonged bed rest
  2. The client's maintaining a semi-Fowler position
  3. Cerebral hypoxia
  4. IV fluids of 2.5­3 liters in 24 hours

Answer(s): C

Explanation:

(A) Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. (B) The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. (C) Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. (D) Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5­3 liters in a 24-hour period.



The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:

  1. Prolonged bed rest
  2. The client's maintaining a semi-Fowler position
  3. Cerebral hypoxia
  4. IV fluids of 2.5­3 liters in 24 hours

Answer(s): C

Explanation:

(A) Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. (B) The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. (C) Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. (D) Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5­3 liters in a 24-hour period.



Page 165 of 431



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Naveen Ahlam commented on November 29, 2024
Great stuff
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Isadora Guimarães commented on November 10, 2024
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