A nurse is providing teaching to a client who has a new colostomy. which of the following actions

1.A nurse is obtaining a health history while admitting a client. The client tells the nurse, "lam under a

lot of stress right now." Which of the following manifestations should the nurse expect?

Increased salivation

Decreased urine output

Elevated heart rate

Constricted pupils

2. A nurse is creating a plan of care for a client who has left

sided hemiplegia Which of the following interventions should the nurse include?

A) instruct the pt to move forward to the left side whem ambulating to avoid

falls.

B) rest the client left arm over their chest.

C) apply an orthotic boot on the client left foot.

?? D) Place a thick pillow behind the client head to increase cervical flextion

3.a nurse is admitting a client who is at risk for falls to a medical- surgical unit.

which of the following actions should the nurse take?

??a. Elevate full- length side rails on both sides of the client's bed

b. Provide the client with a night

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c. Place the bedside table 0.9m (3feet) away from the bed

d. Keep the cleint's room temperature at 19 c (64.4 )

4.A nurse is preparing to provide tracheostomy care for a client. Which of the

following actions should the nurse plan to take?

a. Cut a 4 inch x 4 inch (10 cm x 10cm) gauze pad to place under the

flangses of trachesotmy tube.

b. Secure the tracheostomy in place with a collar that has hook- and loop

fasteners

c. Wear clean gloves while cleaning the inner cannula

d. Cleanse the skin around the stoma with full strength hydrogen peroxide

5.a home health nurse is caring for a client who has a chronic illness and

recently moved in with their adult child. which of the following statements by

the client should indicate to the nurse that that client has adapted to their new

situational role?

a. I am looking forward to being able to be independent again

b. I've never been the kind of person to ask others for help

c. I really don't know what I'm supposed to do all day

d. It's nice having other people cook for me.

5.A nurse is caring for a client who has colostomy. Which of the following actions

should the nurse take ?

a. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma

b. Rub the peristomal skin dry after clening

c. Change the pouch once every 24 hr

d. Apply the pouch while the skin barrier is still damp