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Questions 158

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Question 1 of 5

The nurse is teaching a client with a new colostomy about appliance care. Which instruction should be included?

Correct Answer: B

Rationale: Emptying the colostomy pouch when one-third to one-half full prevents leakage and skin irritation. Changing every 12 hours is excessive, soap may leave residue, and lotion can interfere with adhesion.

Question 2 of 5

The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?

Correct Answer: A

Rationale: Diminished femoral pulses in a newborn suggest coarctation of the aorta, a cardiac anomaly, due to reduced blood flow to the lower extremities. The other findings are normal or nonspecific.

Question 3 of 5

Twenty-four hours after an uncomplicated labor and delivery, a client's WBC is 12,000 cu/mm. The elevation in the client's WBC is most likely an indication of:

Correct Answer: A

Rationale: A WBC of 12,000 cu/mm post-delivery is normal due to the physiological stress of labor, causing leukocytosis. Infection, viruses, or dehydration are less likely without other symptoms.

Question 4 of 5

A client with a history of a burn injury is being taught about wound care. The nurse should teach the client to:

Correct Answer: C

Rationale: Keeping a burn wound covered and moist promotes healing and prevents infection. Harsh soaps, ice, and air exposure can damage tissue or delay healing.

Question 5 of 5

The nurse is performing an assessment on a newborn with suspected coarctation of the aorta. Which finding is most likely?

Correct Answer: A

Rationale: Coarctation of the aorta causes narrowed aortic flow, leading to diminished femoral pulses. Murmurs may occur, but pulse discrepancy is most characteristic.

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