A nurse is giving discharge instructions to a
client who has a new ileostomy. Which of the
following statements by the client indicates
an understanding of the teaching?
■ A. "My stoma size will stay the same, even after it
has healed."
■ B. "My stoma will drain loose, dark green fluid."
■ C. "I will change my pouch system every 2 weeks."
■ D. "I will ensure that my medications are enteric
coated."
✓ CORRECT ANSWER: D. "I will ensure that my
medications are enteric coated."
Rationale: Enteric-coated medications may not dissolve
and absorb properly with an ileostomy because the
small intestine transit time is faster. The client should
consult their provider about medication forms. The
stoma shrinks as healing occurs, ileostomy output is
liquid/green initially then yellow-green, and pouches are
changed every 3-7 days.
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Question 2 of 180
A nurse is performing postmortem care on a client. Which of the following actions should the
nurse take?
■ A. Tape the eyelids closed
■ B. Remove dentures and place in a labeled container
■ C. Cover body with a clean sheet
■ D. Lower the head of the bed to a supine position
✓ CORRECT ANSWER: C. Cover body with a clean sheet
Rationale: Covering the body with a clean sheet preserves the client's dignity. Eyelids should be gently closed
without tape. Dentures should remain in the mouth to maintain normal facial appearance unless facility policy states
otherwise. The head of the bed should be slightly elevated to prevent discoloration of the face.
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A nurse receives change-of-shift report. Which of the following clients should the nurse
attend to first?
■ A. A client who has a productive cough and an oral temperature of 36°C (96.8°F)
■ B. A client who reports tingling in the fingers following a thyroidectomy
■ C. A client who is in a long leg cast and has +2 pedal pulses bilaterally
■ D. A client who has dark, foul-smelling urine and a urine output of 320 mL in the last 8 hr
✓ CORRECT ANSWER: B. A client who reports tingling in the fingers following a thyroidectomy
Rationale: Tingling in the fingers after a thyroidectomy indicates hypocalcemia from inadvertent parathyroid
removal, which can lead to tetany and respiratory arrest. This is the most life-threatening finding requiring
immediate assessment.
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Question 4 of 180
A nurse in the emergency department is providing discharge teaching to a client who has a
sprained ankle. Which of the following should the nurse include in the teaching?
■ A. Maintain foot above the level of the head
■ B. Expect numbness and tingling for the first 24 hr
■ C. Apply ice on the ankle for 20 min intervals
■ D. Perform range of motion exercises for the affected joint
✓ CORRECT ANSWER: C. Apply ice on the ankle for 20 min intervals
Rationale: Ice applied in 20-minute intervals reduces swelling and pain in a sprained ankle. The foot should be
elevated above the level of the heart (not head). Numbness and tingling are abnormal and should be reported.
ROM exercises are delayed until acute inflammation subsides.
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