Nursing Elites

1. What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?

• A. Cleanse the stoma with hydrogen peroxide and water.
• B. Apply a moisture barrier cream to the peristomal skin.
• C. Measure the stoma using a stoma guide.
• D. Use a dry gauze pad to clean the stoma.

Correct answer: C

Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.

2. The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?

• A. Raise the bed to a comfortable working level.
• B. Bend the client's knee.
• C. Move the knee toward the chest as far as it will go.
• D. Cradle the client's heel.

Correct answer: D

Rationale: When providing passive ROM exercises to the hip and knee for an unconscious client, it is essential to support the joints of the knee and ankle. The next action should be to cradle the client's heel and gently move the limb in a slow, smooth, firm, but gentle manner. This helps maintain joint mobility and prevent contractures.

3. When culturing a wound, the nurse should obtain the sample from which part of the wound?

• A. The outer edges of the wound.
• B. All necrotic sections of the wound.
• C. Areas containing purulent or pooled exudates.
• D. Any particularly painful area of the wound.

Correct answer: C

Rationale: To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions.

4. Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?

• A. Use sterile technique when applying the compresses.
• B. Leave the compresses on the area continuously, pouring warm solution on the area when it cools down.
• C. Alternate warm compresses with cold compresses.
• D. Apply a wet dressing and cover it with a dry dressing.

Correct answer: A

Rationale: Using sterile technique when applying the compresses is crucial to prevent infection and promote wound healing. Ensuring a clean environment during wound care reduces the risk of introducing pathogens that can lead to complications. Proper infection control measures play a significant role in the healing process of open wounds. Choice B is incorrect because leaving the compresses on continuously can lead to skin damage or thermal injury. Choice C is incorrect as alternating warm compresses with cold compresses is not appropriate for an open wound. Choice D is incorrect as applying a wet dressing without following specific orders can be detrimental to wound healing.

5. During the insertion of a nasogastric tube (NGT), the client begins to cough and gag. What action should the healthcare professional take?

• A. Stop advancing the tube and allow the client to rest
• B. Remove the tube and try again after a few minutes
• C. Continue inserting the tube while the client sips water
• D. Withdraw the tube slightly and pause before continuing

Correct answer: D

Rationale: When a client begins to cough and gag during the insertion of a nasogastric tube, withdrawing the tube slightly and pausing is the appropriate action. This technique helps prevent further irritation, gives the client a moment to recover, and allows for a smoother continuation of the insertion process. Choice A is incorrect because allowing the client to rest without adjusting the tube position might not address the issue. Choice B is incorrect as removing the tube without addressing the cause of coughing and gagging may lead to repeated discomfort. Choice C is incorrect as continuing to insert the tube while the client is experiencing difficulties can increase discomfort and potential complications.

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