Nursing Elites

1. What intervention should the nurse implement for the client who has an ileal conduit?

• A. Pouch the stoma with a one-inch margin around the stoma
• B. Refer the client to the United Ostomy Association for discharge teaching
• C. Report to the healthcare provider any decrease in urinary output
• D. Monitor the stoma for signs and symptoms of infection every shift

Correct answer: C

Rationale: The correct intervention for a client with an ileal conduit is to report any decrease in urinary output to the healthcare provider. Decreased urinary output in these clients may indicate a blockage or another complication, which requires immediate attention. Monitoring the stoma for signs of infection (Choice D) is important but not the priority when compared to a decrease in urinary output. Pouching the stoma with a one-inch margin around it (Choice A) is incorrect as it does not address the issue of decreased urinary output. Referring the client to the United Ostomy Association (Choice B) is not necessary in this immediate situation where a potential complication is suspected.

2. Which dietary change is most beneficial for a patient with hypertension?

• A. Increased sodium intake
• B. Decreased potassium intake
• C. Increased fiber intake
• D. Increased cholesterol intake

Correct answer: C

Rationale: The correct answer is C: Increased fiber intake. A diet high in fiber is beneficial for patients with hypertension as it helps lower blood pressure. Increased sodium intake (choice A) is not recommended as it can raise blood pressure. Decreasing potassium intake (choice B) is not advisable as potassium helps regulate blood pressure. Increased cholesterol intake (choice D) is also not recommended as high cholesterol levels can contribute to cardiovascular issues, including hypertension.

3. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?

• A. The client’s BP is 110/70
• B. The client’s potassium level is 3.4 mEq/L
• C. The client has a barky cough
• D. The client’s apical pulse is 56

Correct answer: D

Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering the medication as the blood pressure is within a normal range for a client with essential hypertension. Choice B is not directly related to the administration of a beta blocker. Choice C suggests a potential side effect of an ACE inhibitor, not a beta blocker.

4. Warfarin (Coumadin) is an anticoagulant and interferes with the action of:

• A. Platelets
• B. Vitamin K
• C. Calcium
• D. Vitamin B12

Correct answer: B

Rationale: The correct answer is B: Vitamin K. Warfarin works by inhibiting the action of vitamin K, which is crucial for the synthesis of clotting factors in the blood. By interfering with vitamin K, warfarin decreases the production of these clotting factors, thereby prolonging the time it takes for blood to clot. This is why individuals on warfarin therapy need to monitor their vitamin K intake. Choices A, C, and D are incorrect because warfarin does not directly interfere with platelets, calcium, or vitamin B12.

5. Which of the following statements does NOT apply to a nursing plan of care?

• A. It contains short-term goals
• B. It is developed by the patient's physician
• C. It must be continually evaluated
• D. It contains long-range goals

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.

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