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Question 1 of 5

A nurse is caring for a client who has just undergone an ileostomy procedure. The nurse expects how much drainage from the ileostomy during the first 24 hours post-op?

Correct Answer: B

Rationale: Ileostomy drainage in the first 24 hours post-op is typically 500-1,000 mL due to liquid stool output. 800 mL is the most reasonable estimate.

Question 2 of 5

During a pre-op assessment, the nurse would chart which finding(s) as subjective data? Select all that apply.

Correct Answer: B,C,E

Rationale: Subjective data are client-reported, including statements about surgery concerns, weight loss, and pain ratings. Sweating/wringing hands and blood pressure are objective (observable/measurable).

Question 3 of 5

The nurse is assessing a client with an altered level of consciousness. One of the first signs of altered level of consciousness is:

Correct Answer: C

Rationale: Restlessness is often an early sign of altered consciousness, indicating neurological changes before more severe symptoms appear.

Question 4 of 5

Which finding is associated with Tay Sachs disease?

Correct Answer: B

Rationale: Cherry-red spots on the macula are a classic finding in Tay-Sachs disease due to lipid accumulation in retinal ganglion cells.

Question 5 of 5

Which of the following techniques is recommended for removing a tick from the skin?

Correct Answer: C

Rationale: Using tweezers to pull the tick steadily minimizes the risk of leaving mouthparts in the skin.

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