Question

A nurse is assisting in the care of a light-skinned client who has an ileostomy.

Answer 1

Correct Highlights :

Client will not look at stoma.
Client states they are not interested in learning about stoma care
Skin surrounding stoma is reddened and has small open areas.
Stoma with small amount of bleeding noted during cleaning

Rationale :

🔷 Psychological denial – Avoidance of looking at or learning stoma care shows maladaptation and requires nursing support.

🔷 Skin breakdown – Reddened skin and open areas signal improper pouch fit or leakage, needing intervention.

🔷 Bleeding risk – Even a small amount of bleeding should be assessed, as it may indicate trauma or infection.

🔷 Teaching opportunity – The client’s refusal indicates readiness to learn is impaired, requiring emotional support and gradual teaching.

🔷 Priority focus – Protecting the peristomal skin and encouraging acceptance are essential for long-term stoma care.

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Answer 2

Correct Answers:

1 syringe

Rationale :

💠 Mixable insulins – Regular and NPH insulin can be safely mixed in one syringe.

💠 Fewer injections – Reduces needle sticks, increasing client comfort and compliance.

💠 Correct sequence – Air into NPH first, then regular; withdraw regular insulin first to prevent contamination.

💠 Safety principle – One syringe ensures accurate combined dosing without errors from separate injections.

💠 Efficiency – Combining reduces time, cost, and supplies needed.

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Answer 3

Correct Answers:

Eat raw vegetables.

Rationale :

✔️ Fiber source – Raw vegetables provide insoluble fiber, which adds bulk to stool.

✔️ Stimulates peristalsis – Increased bulk stimulates intestinal motility, relieving constipation.

✔️ Water retention – Fiber helps retain water in the stool, preventing hard stools.

✔️ Non-pharmacologic – Diet modification is safer than chronic laxative use.

✔️ Long-term solution – Promotes sustainable bowel health and prevents recurrent constipation.

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Answer 4

Correct Answers:

Wash the puncture site with soap and water.

Rationale :

✳️ Immediate decontamination – Soap and water remove surface contaminants quickly.

✳️ Prevents infection – Reduces risk of bloodborne pathogens like HIV or hepatitis.

✳️ First step – Always the initial step before reporting or prophylaxis.

✳️ Not squeezing – Squeezing increases tissue trauma without benefit.

✳️ Precedes reporting – Must be done before documenting and seeking medical care.

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Answer 5

Correct Answers:

Ask the client's full name and date of birth.

Rationale :

👉 Two identifiers – Name + DOB are the standard identifiers.

👉 Prevents errors – Ensures meds/procedures are given to the correct patient.

👉 Room numbers unsafe – Can change and are not reliable.

👉 Joint Commission standard – Requires two approved identifiers.

👉 Patient participation – Engages client in safety verification.

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Answer 6

Correct Answers:

Use a filter needle to draw up the medication.

Rationale :

🍃 Glass fragments – Filter needle prevents tiny glass shards from entering syringe.

🍃 Safety step – Protects client from embolism or tissue injury.

🍃 Best practice – Always used when withdrawing from an ampule.

🍃 Filter removed later – Change to regular needle before injection.

🍃 Medication integrity – Maintains purity of ampule solution.

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Answer 7

Correct Answers:

Cleans the end of the ileostomy pouch before clamping it

Rationale :

⪼ Prevents infection – Cleaning prevents skin contamination and odor.

⪼ Maintains hygiene – Reduces leakage and protects peristomal skin.

⪼ Correct sequence – Drain, clean tip, then clamp.

⪼ Comfort – Keeps client clean and odor-free, improving psychosocial comfort.

⪼ Standard practice – Reflects proper ostomy management training.

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Answer 8

Correct Answers:

Assist the client to the left Sims' position.

Rationale :

♦ Anatomical alignment – Left Sims’ aligns rectum with sigmoid colon.

♦ Gravity aid – Promotes easy flow of solution into colon.

♦ Comfort – Position prevents cramping and injury.

♦ Standard of care – Recommended position for enemas.

♦ Promotes retention – Helps fluid stay longer for effectiveness.

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Answer 9

Correct Answers:

Activate the device immediately after injection.

Rationale :

💎 Prevents needlestick injuries – Activating safety feature right away reduces accidental sticks.

💎 OSHA requirement – Follows workplace safety protocols.

💎 Client + nurse safety – Protects both from bloodborne pathogens.

💎 No recapping – Eliminates risk of recap injury.

💎 Best practice – Consistent with safe injection guidelines.

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Answer 10

Correct Answers:

"You will have a stoma placed in right lower abdomen.”

Rationale :

◈ Anatomical location – Ileum is in the right lower quadrant.

◈ Appearance – Normal stoma is pink/red and moist, not purple.

◈ Stool consistency – Ileostomy drains liquid to semi-liquid stool, not solid.

◈ No pain at stoma – Nerve endings are absent in stoma tissue.

◈ Preoperative teaching – Accurate info reduces fear and misconceptions.

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QLexNursing

1 :
A nurse is assisting in the care of a light-skinned client who has an ileostomy.

Correct Highlights :

2 :
A nurse receives a new prescription from the provider that reads "Give regular insulin 14 units and NPH insulin 28 units subcutaneously at breakfast." How many syringes should the nurse prepare?

3 :
A nurse is caring for an older adult client who reports constipation. Which of the following recommendations should the nurse make?

4 :
A nurse has accidentally punctured his finger with a needle he used to give an 1M injection to a client. Which of the following actions should the nurse take?

5 :
Before administering client medications. the nurse must identify the client. Which of the following methods of identification should the nurse use?

6 :
A nurse is preparing an injection using a single dose glass ampule. Which of the following actions should the nurse take?

7 :
A nurse is assisting with evaluating a newly licensed nurse drain an Ileostomy bag for a client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

8 :
A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

9 :
A nurse is administering an 1M injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

10 :
A nurse is assisting with teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

QLexNursing

1 : A nurse is assisting in the care of a light-skinned client who has an ileostomy.

Correct Highlights :

2 : A nurse receives a new prescription from the provider that reads "Give regular insulin 14 units and NPH insulin 28 units subcutaneously at breakfast." How many syringes should the nurse prepare?

3 : A nurse is caring for an older adult client who reports constipation. Which of the following recommendations should the nurse make?

4 : A nurse has accidentally punctured his finger with a needle he used to give an 1M injection to a client. Which of the following actions should the nurse take?

5 : Before administering client medications. the nurse must identify the client. Which of the following methods of identification should the nurse use?

6 : A nurse is preparing an injection using a single dose glass ampule. Which of the following actions should the nurse take?

7 : A nurse is assisting with evaluating a newly licensed nurse drain an Ileostomy bag for a client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

8 : A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

9 : A nurse is administering an 1M injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

10 : A nurse is assisting with teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

1 :
A nurse is assisting in the care of a light-skinned client who has an ileostomy.

2 :
A nurse receives a new prescription from the provider that reads "Give regular insulin 14 units and NPH insulin 28 units subcutaneously at breakfast." How many syringes should the nurse prepare?

3 :
A nurse is caring for an older adult client who reports constipation. Which of the following recommendations should the nurse make?

4 :
A nurse has accidentally punctured his finger with a needle he used to give an 1M injection to a client. Which of the following actions should the nurse take?

5 :
Before administering client medications. the nurse must identify the client. Which of the following methods of identification should the nurse use?

6 :
A nurse is preparing an injection using a single dose glass ampule. Which of the following actions should the nurse take?

7 :
A nurse is assisting with evaluating a newly licensed nurse drain an Ileostomy bag for a client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

8 :
A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

9 :
A nurse is administering an 1M injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

10 :
A nurse is assisting with teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?