Nursing Elites

1. A client is post-operative day one following a colostomy surgery. The nurse notices the stoma is dark purple. What is the most appropriate action?

• A. Document the finding and continue to monitor.
• B. Apply warm compresses to the stoma.
• C. Notify the healthcare provider immediately.
• D. Encourage the client to ambulate.

Correct answer: C

Rationale: A dark purple stoma may indicate compromised blood flow to the stoma, which is an emergency. Immediate notification of the healthcare provider is necessary to prevent further complications. Simply documenting and monitoring the finding (Choice A) could lead to delays in addressing a potentially serious issue. Applying warm compresses to the stoma (Choice B) may not address the underlying cause of the dark purple color. Encouraging the client to ambulate (Choice D) is not the priority when a compromised blood flow to the stoma is suspected.

2. A nurse is caring for a 60-year-old man who is scheduled to have coronary bypass surgery in the morning. He tells the nurse that he is afraid that he will die and he is scared of the surgery. What is the best reply for this nurse to give him?

• A. There is no reason to be scared. My father had this surgery, and now he’s playing tennis with his friends almost every day.
• B. I would be scared too. It’s a natural thing to feel. Don’t worry. Everything will be alright.
• C. You’re scared?
• D. The doctor has performed hundreds of successful bypass surgeries. I have a lot of faith in him.

Correct answer: C

Rationale: The best reply for the nurse to give the patient is option C: 'You’re scared?' This response reflects empathy and understanding, acknowledging the patient's feelings of fear. By directly addressing the patient's emotions, the nurse encourages further expression of concerns, which is crucial in providing emotional support. Choices A and D may come off as dismissive of the patient's feelings by downplaying his fear or shifting the focus to others' experiences. Choice B, although acknowledging the patient's fear, does not actively engage with the patient's emotions or encourage further discussion.

3. All of the following are posture and body alignment problems EXCEPT:

• A. Kyphosis
• B. Scoliosis
• C. Thrombosis
• D. Lumbar lordosis

Correct answer: C

Rationale: Thrombosis is a condition involving blood clots and is not related to posture or body alignment, unlike kyphosis, scoliosis, and lumbar lordosis, which are spinal alignment issues. Kyphosis refers to excessive outward curvature of the spine, scoliosis is characterized by a sideways curvature of the spine, and lumbar lordosis involves an exaggerated inward curve in the lower back. Thrombosis, on the other hand, is a condition where blood clots form in the blood vessels, not a posture or body alignment problem.

4. A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the nurse implement?

• A. Massage the calf and foot
• B. Elevate the leg above the heart
• C. Check the pedal pulse in the affected leg
• D. Extend the leg and flex the foot

Correct answer: D

Rationale: The correct intervention for a client in active labor complaining of a leg cramp is to extend the leg and flex the foot. This action helps stretch the muscles that are cramping, providing relief. Massaging the calf and foot (Choice A) may not be as effective for relieving the cramp. Elevating the leg above the heart (Choice B) is not indicated for a leg cramp. Checking the pedal pulse in the affected leg (Choice C) is unrelated to addressing the leg cramp.

5. While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement?

• A. Swab the oral cavity with a washcloth
• B. Use oral swabs with normal saline
• C. Provide a Yankauer tip for oral suction
• D. Support the head with a small pillow

Correct answer: B

Rationale: Using oral swabs with normal saline is the best intervention in this scenario as it effectively cleans the oral cavity without causing irritation or dryness, which is crucial for an unconscious client. Swabbing the oral cavity with a washcloth may not provide thorough cleaning, and it can potentially cause irritation. Providing a Yankauer tip for oral suction is not necessary unless there are excessive secretions that need to be suctioned. Supporting the head with a small pillow, although important for comfort, is not directly related to oral care in an unconscious client.

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