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. When assessing a male client, the nurse finds that he is fatigued and experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which condition?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The symptoms of fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias are classic manifestations of hypokalemia. Potassium plays a vital role in muscle function and cardiac conduction, so a deficiency can lead to these symptoms. Checking the client’s laboratory values for potassium levels will help confirm the presence of hypokalemia.

3. A client is in the radiology department at 0900 when the prescription for levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?

• A. Contact the healthcare provider and complete a medication variance form.
• B. Administer the Levaquin at 1300 and resume the 0900 schedule the next day.
• C. Notify the charge nurse and complete an incident report to explain the missed dose.
• D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

Correct answer: D

Rationale: To maintain a therapeutic level of medication, the nurse should administer the missed dose as soon as possible and adjust the administration schedule to prevent dangerously high levels of the drug in the bloodstream (D). It is important to document the reason for the delayed dose. Contacting the healthcare provider and completing a medication variance form (A) may cause unnecessary delays. Notifying the charge nurse and completing an incident report (C) should be done after addressing the immediate medication administration issue. Administering the medication at 1300 and resuming the 0900 schedule the next day (B) could lead to suboptimal therapeutic levels and potential complications.

4. The nurse is completing a client's preoperative routine and finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?

• A. Witness the client's signature on the permit.
• B. Answer the client's questions about the surgery.
• C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
• D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

Correct answer: C

Rationale: The nurse should inform the surgeon immediately that the operative permit is not signed and that the client has questions about the surgery. It is crucial for the surgeon to be aware of the situation so they can address the client's concerns, explain the procedure, and obtain the necessary signed permit before proceeding with the surgery. This ensures informed consent and compliance with preoperative protocols.

5. After ensuring correct tube placement, what action should the nurse take next when administering medications through a nasogastric tube (NGT) connected to suction?

• A. Clamp the tube for 20 minutes.
• B. Flush the tube with water.
• C. Administer the medications as prescribed.
• D. Crush the tablets and dissolve in sterile water.

Correct answer: B

Rationale: After ensuring the correct placement of the NGT, the nurse should flush the tube with water to prevent any obstructions and ensure proper medication delivery. Flushing the tube is essential before, after, and in between each medication administration. Clamping the tube for 20 minutes should be done after all medications are administered to prevent clogging. Administering medications as prescribed and preparing medications by crushing tablets and dissolving them in sterile water should only be done after the tube has been appropriately flushed to maintain its patency and effectiveness.

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