While performing the initial postoperative assessment of a client who has undergone a total proctocolectomy, with placement of a permanent ileostomy, the nurse notes that the drainage from the ileostomy appears loose, dark green in color, and
contains some blood. What is the nurse's best action at this time? A. Notify the physician.
B. Document the finding as the only action.
C. Irrigate the ileostomy.
D. Send a stool sample for culture and sensitivity.
B
The initial drainage from the ileostomy appears loose, dark green, and may contain some blood. The nurse should document this normal finding. The stool consistency and color will change over time to a yellow-green or brown.
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For clients with lung disease, which of the following factors should determine the amount of aerobic activity?
A) Dyspnea B) Heart rate C) Bronchospasm D) Infection
A nurse is providing a client with instructions regarding breast self-examination (BSE)
Which of the following statements by the client would indicate that the teaching has been successful? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "I should perform BSE 1 week prior to the start of my period." 2. "When I reach menopause, I will perform BSE every 2 months." 3. "Knowing the density of my breast tissue is important." 4. "I should inspect my breasts while standing with my arms down at my sides." 5. "I should inspect my breasts while in a supine position with my arms at my sides."
A patient who will begin taking trimethoprim-sulfamethoxazole (TMP-SMX) asks the nurse why the combination drug is necessary. The nurse will explain that the combination is used to
a. broaden the antibacterial spectrum. b. decrease bacterial resistance. c. improve the taste. d. minimize toxic effects.
You learn you will be caring for an adult female Amish patient. It is important for you to know that your patient likely prefers to
A) wear a short-legged, long-underwear-type garment at all times. B) remain covered from her neck to her ankles. C) wear a medicine bag around her neck. D) wear Kara (bracelets) on her right wrist.