Question

A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching?

Answer 1

Correct Answers:

The client should follow a high fiber diet to establish bowel regularity

Rationale :

💎A high-fiber diet helps promote bulk formation, stimulate peristalsis, and normalize bowel movements in clients with chronic constipation.

💎Fiber acts like a natural laxative by increasing stool weight and decreasing intestinal transit time.

💎Establishing dietary habits with consistent fiber intake throughout the day, along with adequate hydration, is key to promoting long-term bowel regularity.

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Answer 2

Correct Answers:

Cover the wound with a moist, sterile gauze dressing

Rationale :

📌The nurse observes wound dehiscence, indicated by the separation of wound edges and drainage.

📌The priority is to protect the exposed tissue using a sterile, moist dressing, which maintains a moist healing environment and minimizes infection risk.

📌This is a surgical emergency that requires immediate protection before further assessment or notifying the provider.

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Answer 3

Correct Answers:

Purplish-colored stoma

Rationale :

📌A healthy stoma should appear moist, shiny, and red or rose-colored, indicating good perfusion.

📌A purplish or dusky stoma suggests compromised blood flow or ischemia, requiring immediate notification of the provider.

📌This may be a sign of stoma necrosis, a serious complication needing urgent evaluation.

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Answer 4

Correct Answers:

Having a unity catheter

Rationale :

💥Indwelling urinary catheters significantly increase the risk of urinary tract infections (UTIs) by providing a direct pathway for bacteria to enter the bladder.

💥Catheter-associated UTIs (CAUTIs) are among the most common hospital-acquired infections.

💥Prevention includes limiting catheter use and ensuring aseptic technique during insertion and care.

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Answer 5

Correct Answers:

"It might take up to 3 days for the medication to work."

Rationale :

💥Docusate sodium is a stool softener that works by increasing water content in the stool, making it easier to pass.

💥It does not produce immediate effects and may take 1 to 3 days to relieve constipation.

💥This information helps set realistic expectations and improves adherence.

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Answer 6

Correct Answers:

Serosanguineous

Rationale :

💥Serosanguineous drainage is pink to pale red and watery, indicating a mixture of serous fluid and blood.

💥It is commonly seen in early wound healing stages and does not usually indicate infection.

💥Recognizing the type of drainage helps the nurse assess the wound's healing status.

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Answer 7

Correct Answers:

Pressure points

Rationale :

🎯Pressure points (e.g., sacrum, heels, elbows) are the most vulnerable sites for skin breakdown, especially in immobile patients.

🎯They must be assessed first during skin integrity evaluations to detect early signs of pressure ulcers, such as non-blanchable erythema.

🎯Early intervention can prevent serious complications.

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Answer 8

Correct Answers:

Explain the procedure.

Rationale :

🟡Patient anxiety often stems from fear of the unknown.

🟡Explaining the dressing change procedure in advance builds trust, reduces anxiety, and promotes informed cooperation.

🟡It reflects the nurse’s role in patient education and therapeutic communication.

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Answer 9

Correct Answers:

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen

Rationale :

💎Proper wound culture technique requires that the wound be cleansed with sterile normal saline before specimen collection to remove surface contaminants and exudate, ensuring the sample reflects only organisms present in the wound tissue, not superficial skin flora.

💎This step is essential to obtain an accurate culture and sensitivity, which guides targeted antibiotic therapy.

💎Failing to cleanse first may result in a false-positive culture, leading to inappropriate treatment.

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Answer 10

Correct Answers:

Dark-colored urine

Rationale :

📌A client with dehydration will exhibit dark, concentrated urine, which indicates a high solute concentration and low fluid volume.

📌As the body conserves water, the kidneys produce less dilute urine. This is a reliable and non-invasive indicator of fluid volume deficit.

📌Other common findings may include poor skin turgor, dry mucous membranes, tachycardia, and hypotension.

📌Early identification of concentrated urine helps prevent further fluid imbalance and complications such as hypovolemia.

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QLexNursing

1 : A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching?

2 : A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes a wide separation of the wound edges with light serosanguineous drainage. Which of the following actions should the nurse perform first?

3 : A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

4 : Which of the following is a common risk factor for developing a urinary tract infection (UTI)?

5 : A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

6 : A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

7 : The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?

8 : The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take?

9 : A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

10 : A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?