The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown:

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Question 1 of 5

The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown:

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

Which of the following would you include as risk factors for the development of skin cancer when assessing the integumentary system?

Correct Answer: B

Rationale: Advancing age by itself is not a risk factor. If that person has been exposed to a lot of sun there may be increased risk, but that information is not given here. There is a known genetic risk, with some cancers being seen to be present in families with low risk factors. Those with dark pigmentation develop skin cancer, but at a lower rate than those with low amounts of pigmentation. White collar jobs, which occur in offices and inside buildings, are a low risk for skin cancer.

Question 4 of 5

Justin Mack, 20, was critically injured in a motorcycle accident and is not expected to survive. His parents, after arriving at the hospital from several hundred miles away, are asked to give important information about Justin, including:

Correct Answer: B

Rationale: Finding out about his childhood immunizations is of minor importance, given the prognosis. Getting information about whether Justin expressed the desire to donate his organs would be important at this time. Asking about the number of siblings might be a conversation opener, but is not of high importance to Justin's care. Previous hospitalizations and surgeries are irrelevant unless the organ donation is being considered, and this would then be important to learn.

Question 5 of 5

A 35-year-old female client has returned to her room following surgery on her right femur. She has an IV of D5 1/2 NS infusing at 125 cc/hr, and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. The client last voided 5 1/2 hours ago when she was given her preoperative medication. To monitor and promote the return of urinary function after surgery, the nurse should:

Correct Answer: C

Rationale: Provision of food and fluids promotes bowel elimination. Postoperative nutritional needs are physician determined, not client determined. Increasing IV fluids postoperatively will not cause a client to void. Any change in the rate of administration of IV fluids is determined by the physician, not the nurse. If the postoperative client with normal kidney function cannot void 8 hours after surgery, the client is retaining urine. The client may need catheterization or medication. The physician will provide orders for either, as necessary. While morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.

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