The nurse is caring for a patient who had a colostomy placed 5 days earlier. The nurse notes that the stoma is red and moist. Which action should the nurse take?
a. Notify the physician immediately.
b. Apply pressure.
c. Note the condition of the stoma in her notes.
d. Change the appliance pouch.
Question 2In caring for a patient who has an abdominal binder, it is expected that the nurse will do which of the following? (Select all that apply.)
a. Remove the binder and assess the skin and wound every 8 hours.
b. Evaluate the patient's ability to breathe deeply and cough effectively every 4 hours.
c. Evaluate the patient's pulmonary function every 8 hours.
d. Remove the binder at least daily.
Question 3What is an appropriate technique to use when teaching an older patient about self-medication in the home?
a. Speak very loudly.
b. Teach the family separately.
c. Provide frequent pauses.
d. Provide fewer but longer teaching sessions.
Question 4The nurse is caring for a patient who has an ostomy. The nurse notices that the effluent ranges from a thick liquid to a semi-formed stool. The nurse recognizes that this is indicative of which location?
a. Descending colon
b. Ileal portion of the small intestine
c. Sigmoid colon
d. Transverse or ascending colon
Question 5Negative-pressure wound therapy (NPWT) would be contraindicated in which of the following? (Select all that apply.)
a. Dehisced wounds
b. Pressure ulcers
c. Malignancies
d. Necrotic tissue with eschar
Question 6When teaching the patient about performing trach care, which of the following is an acceptable technique?
a. Remove the old ties before applying the new.
b. Keep two trach tubes of the same size at the bedside.
c. Place the new trach tie, then remove the old tie.
d. Dispose of all old supplies and replace with new.
Question 7The nurse is caring for a patient with an ostomy. The nurse notes that the ostomy is putting out watery effluent. The nurse recognizes that this is indicative of which location?
a. Descending colon
b. Sigmoid colon
c. Ileal portion of the small intestine
d. transverse colon
Question 8Which of the following are examples of wounds that heal by secondary intention? (Select all that apply.)
a. Burns
b. Surgical incisions
c. Infected wounds
d. Deep pressure ulcers
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