The patient who has undergone creation of urinary diversion verbalizes that the stoma is a dark purplish color. This nurse is aware of the following:
A) The stoma is healthy.
B) The stoma is infected.
C) Vascular supply to the stoma may be compromised.
D) The ostomy appliance around the stoma is too loose.
Ans: C
Feedback: A healthy stoma is beefy red. A change from this normal color to a dark purplish color suggests that the vascular supply may be compromised.
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The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal
" What response is best? 1. "We'll take good care of you and your baby. You'll be home before you know it." 2. "You'll be wearing long stockings to prevent blood clots from forming in your legs." 3. "You will have a lot of pain, but there are medications that we give when it gets bad." 4. "You won't be able to nurse until the baby is 12 hours old, because of your epidural."
The evaluation and admission process for entry to the home health care system includes physical and psychosocial examination, explanation of the patient's rights, and evaluation of family, home, and nursing interventions. What is the normal minimum time for the admission visit?
a. 30 minutes b. 1 hour c. 2 hours d. 3 hours
A client tells the nurse that her faith has kept her grounded and hopeful during periods of illness. Faith is defined as a:
a. factor that enables one to cope. b. set of beliefs and practices associated with an organization c. sense of connectedness. d. belief in and relationship with a higher power.
The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client?
a. Administer this medication before meals to aid absorption. b. Instruct the client to ask for assistance when arising from bed. c. Give the medication with milk to prevent stomach upset. d. Monitor the potassium level and check for symptoms of hypokalemia.