The nurse is instructing a client on ostomy care. What should be included in this teaching? - CORRECT
ANSWER✅✅Secure the faceplate to the drainage appliance so no skin around the stoma is exposed
The skin around a stoma is very susceptible to irritation and breakdown. To avoid skin irritation, the
faceplate to the drainage pouch needs to fit close enough to the stoma so as not to expose any other
skin.
A nurse is feeding a client. Which of the following statements would help a person maintain dignity
while being fed? - CORRECT ANSWER✅✅"What part of your dinner would you like to eat first?"
"What part of your dinner would you like to eat first?", allows the client to feel in control of their meal
choices.
When assessing a client's intake and output (I and O), the nurse notes that the client has voided 120 mL
of urine in the past 2 hours. What is the next nursing action? - CORRECT ANSWER✅✅Document the
client's urinary output in the chart
Normally, the kidneys produce urine at a rate of approximately 60 ml/hour or about 1500 ml/day.
The nurse is concerned that an older client is at risk for aspiration. What feeding techniques should the
nurse instruct the family to use once the client is discharged?
Select all that apply - CORRECT ANSWER✅✅Thicken all fluids.
Place the client in a seated position
Select food the client prefers.
Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to
reduce this risk include thickening fluids. Many older adults can swallow foods with thicker consistency
more easily than thin liquids. Techniques to reduce this risk include eating in a seated position.
Techniques to reduce this risk include focusing on food preferences. Keeping the head of the bed at a
15-degree angle would encourage aspiration.
, You have an order for Heparin 5,000 units subcutaneous q8h. A multi-dose vial of 20,000 units/mL is
available. How many milliliter(s) will you give? Provide the numerical answer only; do not write the
units. - CORRECT ANSWER✅✅0.25 mL
What is the route of administration for TPN? - CORRECT ANSWER✅✅Intravenous
Total Parenteral Nutrition (TPN)
is high glucose (up to 70% glucose), therefore should be given in a central vein because glucose is caustic
to vessels.
Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they - CORRECT
ANSWER✅✅Would feel more comfortable assuming a normal voiding position.
Assuming a normal voiding position helps patients relax and be able to void; lying in bed is not the
typical position in which people void. Men usually are most comfortable when standing; women are
more comfortable when sitting and squatting. Embarrassment at using the bedpan and worrying about a
urinary tract infection are not related to the lying-in-bed position. Fear of loss of independence is not
related to use of the bedpan or urinal.
Which term describes a condition in which 24-hour urine output is 0 mL? - CORRECT
ANSWER✅✅Anuria
Anuria is synonymous with kidney shutdown or renal failure. Dysuria is painful or difficult urination.
Glycosuria is the presence of sugar in the urine. Pyuria is pus in the urine.
A home care client has both visual and hearing deficits. Although all of the following are important, what
would be a high priorityconcern when planning and implementing care? - CORRECT ANSWER✅✅Safety
Safety is always a special concern for clients with sensory alterations. The nurse must ensure that the
client's environment is as free of danger as possible, and assist the client in developing new self-care
behaviors to compensate for sensory impairments. Nutrition, communication, and comfort are
important but not as critical as safety.