A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma?

A) Pallor
B) Purple-blue
C) Irritation and bleeding
D) Dark red and moist


Ans: D
The ostomy stoma should be dark pink to red and moist. Abnormal findings include paleness (possible anemia), purple-blue color (possible ischemia), or bleeding.

Nursing

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The nurse is caring for a very seriously ill patient in the CCU. The family visits sporadically, stays for only a short time, and does not ask many questions. How could the nurse best begin to involve the family in the patient's care?

A) Ask one family member to assist with the patient's bath. B) Encourage family members to stay longer at each visit. C) Focus nursing efforts on the patient's legal next of kin. D) Ask the family to complete the Critical Care Family Needs Inventory.

Nursing

While the vital signs of a pregnant woman in her third trimester are being assessed, the client complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate?

a. Have the patient stand up and retake her blood pressure. b. Have the patient sit down and hold her arm in a dependent position. c. Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms. d. Have the patient turn to her left side and recheck her blood pressure in 5 minutes.

Nursing

The nurse recognizes that an older adult patient with heart failure is experiencing the effects of inadequate cardiac output, a problem that affects many of the body's systems

Inadequate perfusion of the patient's kidneys leads to which of the following pathophysiological effects? A) Decreased erythropoiesis B) Acid–base imbalances C) Hyperkalemia D) Increased renin release

Nursing

A client newly diagnosed with HIV/AIDS seeks the nurse's assistance with the immediate problem of telling family members about the diagnosis, then regaining an emotional equilibrium. The nurse knows this is the primary goal of:

A) Remotivation therapy. B) Self-esteem intervention. C) Reminiscence therapy. D) Crisis intervention.

Nursing