Question

Please and give rationale

1. A nurse is completing a discharge teaching to a client following a sigmoid colostomy. Which of the following statements by the clint indicated a need for further teaching?

a. my stoma should shrink in 3-4 weeks

b. my bowel pattern should be regulated in 4 to 6 weeks

c. I will measure my stoma weekly

d. I will cut the appliance opening 1/8 to 1/16th inch larger to fir the stoma site?

2. A nurse prepares a transfusion of packed RBCs by setting up Y tubing with the 0.9& sodium chloride solution. Thirty min after the start of the transfusion,the client reports feeling warm and is observed to have facial flushing. After stopping the transfusion, which is the following action should the nurse take first?

a. obtain the client's vital signs

b. notify the provider

c. assess the client's lung sounds

d. start infusing the 0.9% sodium chloride solution

3. A nurse is setting up a dressing change on a post operative patient. Which of the following actions should the nurse plan to take to maintain the sterile field?

a. select a work surface at the nurse's hip level

b. place sterile drape on the work station before opening the surgical pack

c. open the first flap of the sterile package toward the nurse's body

d. apply sterile gloves before opening the surgical pack