the nurse is providing discharge instructions to a client with a new colostomy what information should the nurse prioritize
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Nursing Elites

HESI LPN

Adult Health 1 Exam 1

1. What should the nurse prioritize when providing discharge instructions to a client with a new colostomy?

Correct answer: A

Rationale: Correct answer: Skin care around the stoma site. Proper skin care around the stoma site is crucial for preventing skin irritation and infection, which are common issues for patients with new colostomies. While the schedule for colostomy bag replacement (Option B) is important, it is not the priority during initial discharge instructions. Techniques for odor control (Option C) are relevant but secondary to skin care for a new colostomy. Dietary modifications (Option D) may be discussed later but are not the priority at this stage.

2. What is the function of the cervix in reproduction?

Correct answer: B

Rationale: The cervix functions in reproduction by secreting mucus that facilitates the transport of sperm to the uterus. Choice A is incorrect because the cervix does not interpret signals of sexual stimuli. Choice C is incorrect as the site for the union of ovum and sperm is the fallopian tube. Choice D is incorrect as the cervix is not involved in receiving the penis during intercourse.

3. The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen, and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding?

Correct answer: D

Rationale: The correct answer is D. An infiltrated IV occurs when fluid leaks into the surrounding tissue, causing coolness, swelling, and a slow infusion rate. Choice A is incorrect because a rapid solution rate does not typically cause these specific symptoms. Choice B, phlebitis, presents with redness, warmth, and tenderness along the vein, not coolness. Choice C, infection, usually manifests with redness, warmth, and possibly purulent drainage, not coolness and swelling.

4. A client with a history of pulmonary embolism is on anticoagulant therapy. What should the nurse monitor regularly?

Correct answer: A

Rationale: Correct! Monitoring INR is essential in clients on anticoagulant therapy to ensure the blood's clotting time is within the therapeutic range, preventing further embolic events or excessive bleeding. Monitoring blood glucose levels (Choice B), blood pressure (Choice C), and temperature (Choice D) is important for various other conditions but is not directly related to anticoagulant therapy for a client with a history of pulmonary embolism.

5. During the shift change report at an acute care hospital, the charge nurse assigns the Licensed Practical Nurse (LPN) to care for a client. Which task is within the LPN's scope?

Correct answer: C

Rationale: The correct answer is C. LPNs are trained to provide basic nursing care such as wound care. Providing wound care for a stage III pressure ulcer falls within the LPN's scope of practice. Administering IV medication (choice A) requires a higher level of skill and is usually the responsibility of registered nurses. Conducting initial client assessments (choice B) demands more advanced training and is typically performed by registered nurses. Teaching a diabetic client about insulin administration (choice D) involves patient education and is usually within the scope of registered nurses or other healthcare professionals with specific training in diabetic care.

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