Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, "I should:

Correct Answer: B

Rationale: The correct answer is B because keeping the irrigating container less than 18 inches above the stoma helps regulate the flow rate of the solution, preventing discomfort or damage to the stoma. Placing the container too high can cause rapid flow, leading to cramping or leakage. Choices A, C, and D are incorrect. Choice A is incorrect because the client should actually lie on his back, not the left side, to facilitate the irrigation process. Choice C is incorrect as instilling too much solution can cause discomfort or damage to the bowel. Choice D is incorrect because the client should not insert the catheter deeper if cramping occurs, as this could cause injury to the bowel.

Correct Answer: A

Rationale: The correct answer is A: Blood supply to the stoma has been interrupted. A dusky appearance of the stoma indicates poor blood supply, which can lead to tissue ischemia and necrosis. This is a critical finding that requires immediate intervention to prevent further complications. In contrast, the other options are incorrect. Option B is incorrect because a dusky stoma is not a normal finding post-ileostomy surgery. Option C is incorrect as adjusting the ostomy bag will not address the underlying issue of compromised blood supply. Option D is incorrect as an intestinal obstruction would present with different symptoms and would not cause the stoma to appear dusky.

Correct Answer: C

Rationale: The correct answer is C because calling up the latest electrocardiogram results to check the client's progress breaches the client's confidentiality since this action involves disclosing the client's medical information to someone unauthorized to receive it. This violates the client's right to privacy and confidentiality. A, B, and D are incorrect: A: Giving a verbal report to the nurse on the telemetry unit is appropriate as it facilitates continuity of care and is within the scope of healthcare providers involved in the client's treatment. B: Notifying the on-call physician about a change in the client's condition is also essential for timely medical intervention and does not breach confidentiality. D: Updating the client's wife on his condition at his request is permissible as long as the client consents to sharing his medical information with his spouse.

Correct Answer: A

Rationale: Rationale: - Correct answer (A): Paco2 of 30 mm Hg is appropriate because lowering CO2 helps reduce ICP in clients with subdural hematoma. - Incorrect answer (B): Paco2 is not indicative of oxygenation status; it measures CO2 levels. - Incorrect answer (C): Paco2 of 30 mm Hg is low, not normal. - Incorrect answer (D): Paco2 of 30 mm Hg indicates hyperventilation, not hypoventilation.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates an understanding of the dosing schedule for both medications. Fludrocortisone acetate is usually taken in the morning to mimic the body's natural cortisol release, while hydrocortisone is typically taken in divided doses throughout the day to prevent adrenal insufficiency. Option C shows the client plans to take two-thirds of the dose in the morning and one-third in the late afternoon, aligning with the recommended dosing schedule. Option A is incorrect because taking hydrocortisone in the late afternoon is not ideal for mimicking the body's natural cortisol release. Option B is incorrect as taking all hydrocortisone in the morning may lead to suboptimal control of adrenal insufficiency throughout the day. Option D is incorrect because taking the entire dose at bedtime does not align with the recommended dosing schedules for these medications.