A client with a colostomy is being discharged. What teaching is most important for the nurse to provide?

Correct Answer: C

Rationale: In the context of a client with a colostomy being discharged, the most important teaching for the nurse to provide is to empty the ostomy pouch when it is one-third full, which is option C. This is crucial for maintaining skin integrity, preventing leakage, and ensuring proper functioning of the colostomy. By emptying the pouch at the appropriate time, the client can avoid potential complications such as skin irritation, leakage, and discomfort. Option A, changing the ostomy bag daily, is incorrect as it is not necessary to change the entire bag daily unless there is a specific issue. This practice can be wasteful, costly, and may increase the risk of damaging the peristomal skin. Option B, avoiding gas-producing foods like broccoli, is important for some individuals with colostomies to minimize gas and odor, but it is not the most critical teaching point for discharge. It is more of a dietary recommendation rather than a fundamental aspect of colostomy care. Option D, using a skin barrier to protect the surrounding skin, is essential for preventing skin breakdown and irritation; however, it is not as critical as ensuring timely emptying of the ostomy pouch. While using a skin barrier is important, it is a preventive measure rather than a direct action that impacts the functionality of the colostomy. In an educational context, understanding the proper care of a colostomy is vital for nurses working with clients who have undergone ostomy surgery. By prioritizing teachings like timely pouch emptying, nurses can help clients maintain independence, quality of life, and prevent complications related to their colostomy.

Correct Answer: B

Rationale: In a client with diabetic ketoacidosis (DKA), the nurse should closely monitor the blood glucose level, making option B the correct answer. DKA is a serious complication of diabetes characterized by high blood sugar levels, dehydration, and ketone formation. Monitoring blood glucose levels is crucial in managing DKA as it indicates the effectiveness of treatment and helps prevent complications such as cerebral edema. Option A, a white blood cell count of 15,000, may indicate an infection but is not the most critical parameter to monitor in DKA. Option C, a sodium level of 145 mEq/L, is within normal range and not directly related to DKA management. Option D, a serum creatinine level of 1.0 mg/dL, assesses kidney function and may be important for overall health assessment but is not as immediately relevant as monitoring blood glucose levels in DKA. Educationally, understanding the importance of monitoring specific laboratory values in DKA highlights the critical thinking skills required in nursing practice. It reinforces the need for prioritization of care based on the client's condition and the significance of timely interventions to prevent complications and promote positive outcomes for the client.

Correct Answer: A

Rationale: The correct answer is A) Monitor the client's respiratory rate. When a client is receiving morphine, a potent opioid analgesic, there is a risk of respiratory depression as one of the side effects. Respiratory depression can be life-threatening and requires immediate intervention. Therefore, assessing the client's respiratory rate is crucial to detect any signs of respiratory distress early on. Option B) Monitor the client's level of consciousness is important, but respiratory rate takes priority as it directly reflects respiratory function, which is essential for life. Option C) Assess the client's level of pain is important for providing holistic care, but in this scenario, the priority is to ensure the client's physiological safety. Option D) Monitor the client's blood pressure is not the priority in this situation. While it is important to monitor blood pressure, it is not the most critical assessment when a client is receiving morphine and at risk for respiratory depression. In an educational context, this question highlights the importance of prioritizing assessments based on the potential risks associated with specific medications. It emphasizes the need for nurses to be vigilant in monitoring clients for adverse effects and taking prompt action to ensure client safety.

Correct Answer: C

Rationale: In this scenario, the correct lab value that the nurse should review before administering warfarin to a client with deep vein thrombosis (DVT) is the International Normalized Ratio (INR). The INR is specifically used to monitor and adjust warfarin therapy, which is a common anticoagulant medication used to treat and prevent blood clots such as DVT. By checking the INR, the healthcare provider can assess the patient's blood clotting time and determine if the warfarin dosage is within the therapeutic range to effectively prevent clot formation without causing excessive bleeding. Regarding the other options: A) Prothrombin time (PT): While PT is related to warfarin therapy, INR is a more precise measure when monitoring patients on warfarin. B) Hemoglobin and hematocrit (H&H): These values are important for assessing anemia and blood volume but are not directly related to monitoring warfarin therapy. D) Partial thromboplastin time (PTT): PTT is more commonly used to monitor heparin therapy, another type of anticoagulant, not warfarin. Educationally, understanding the rationale behind selecting the correct lab value is crucial for nurses caring for patients on anticoagulant therapy. It ensures safe medication administration and effective management of conditions like DVT, highlighting the importance of monitoring and interpreting lab values accurately in clinical practice.

Correct Answer: A

Rationale: In this scenario, the nurse's priority action should be to stop the transfusion and notify the healthcare provider immediately. This is the correct answer because the client is experiencing signs of a transfusion reaction, which can be life-threatening if not addressed promptly. By stopping the transfusion, the nurse can prevent further harm to the client. Option B, administering an antihistamine, is incorrect because antihistamines are not the first-line treatment for transfusion reactions. Option C, administering acetaminophen, and Option D, administering diphenhydramine, are also incorrect as they do not address the potential serious nature of the client's symptoms. Educationally, this question highlights the importance of prompt recognition and intervention in managing transfusion reactions, a critical aspect of nursing practice. It underscores the significance of prioritizing client safety and advocating for appropriate care in emergency situations. Nurses must be vigilant in monitoring clients during transfusions and prepared to act swiftly in response to any adverse reactions.