1. A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy

established. Which of the following instructions should the nurse include in the teaching?

1) Empty the pouch immediately after meals.

2) Change the entire appliance once a day.

3) Limit fluid intake.

4) Avoid medications in capsule or enteric form.

2. A nurse is caring for a client with severe burns to both lower extremities. The client is

scheduled for an escharotomy and wants to know what the procedure involves. Which of

the following statements is appropriate for the nurse to make?

1) "An escharotomy surgically removes dead tissue."

2) "A cannula will be inserted into the bone to infuse fluids and antibiotics."

3) "A piece of skin will be removed and grafted over the burned area."

4) "Large incisions will be made in the burned tissue to improve circulation."

3. A nurse is collecting data from a client who has a possible cataract. Which of the following

manifestations should the nurse expect the client to report?

1) Decreased color perception

2) Loss of peripheral vision

3) Bright flashes of light

4) Eyestrain

4. A nurse is contributing to the plan of care for a client who has an intestinal obstruction and

is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of

the following interventions should the nurse include in the plan of care?

1) Measure abdominal girth daily.

2) Use sterile water to irrigate the nasogastric tube..

3) Maintain the client in Fowler’s position.

4) Moisten the client’s lips with lemon-glycerin swabs.

5. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical

manifestations should the nurse expect to observe? (Select all that apply.)

1) Buffalo hump

2) Purple striations

3) Moon face

4) Tremors

5) Obese extremities

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