Nursing Elites

1. A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client. What is the nurse's responsibility?

• A. Contact the stoma nurse immediately.
• B. Educate the client on stoma care.
• C. Assess the stoma site for complications.
• D. Arrange for follow-up visits with the stoma nurse.

Correct answer: B

Rationale: The correct answer is B: 'Educate the client on stoma care.' The nurse's primary responsibility in this scenario is to provide education to the client on stoma care. This empowers the client to take care of their colostomy effectively. While it is important to involve the stoma nurse for specialized care, the immediate action required from the nurse is client education. Choice A is incorrect as the immediate action is not to contact the stoma nurse but to educate the client first. Choice C is not the nurse's initial responsibility unless there are obvious complications. Choice D is premature as arranging follow-up visits should come after the client has been educated and initial care has been provided.

2. What is the priority nursing intervention for a patient with a new tracheostomy?

• A. Suction the tracheostomy as needed to maintain a patent airway.
• B. Monitor the patient's oxygen saturation.
• C. Provide humidified air to prevent drying of the airway.
• D. Administer pain medication as prescribed.

Correct answer: A

Rationale: The correct answer is to suction the tracheostomy as needed to maintain a patent airway. After a tracheostomy procedure, the immediate concern is airway patency to prevent respiratory compromise. Suctioning helps clear secretions and maintains a clear airway, reducing the risk of respiratory distress. Monitoring the patient's oxygen saturation (choice B) is important but not the priority compared to ensuring a clear airway. Providing humidified air (choice C) and administering pain medication (choice D) are also essential aspects of care for a patient with a tracheostomy, but they are not the priority when immediate airway management is required.

3. While assessing a migrant farm worker in a mobile health clinic, which of the following findings should the nurse identify as the priority?

• A. Report of back pain associated with twisting at the waist
• B. Absence of a dental health provider
• C. Lives in a home with 25 other migrant workers
• D. Report of muscle twitching and skin rash

Correct answer: D

Rationale: The correct answer is D because muscle twitching and a rash could indicate pesticide poisoning, a serious condition that requires immediate attention in a migrant farm worker. Option A is not the priority as it could be musculoskeletal in nature and managed after addressing urgent issues. Option B, absence of a dental health provider, though important for overall health, is not an immediate priority. Option C, living with 25 other migrant workers, raises concerns about living conditions but does not present an immediate health threat compared to potential pesticide poisoning.

4. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?

• A. Monitor the patient's vital signs.
• B. Check the patient's weight daily.
• C. Measure the patient's intake and output.
• D. Monitor the patient's urine color.

Correct answer: B

Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.

5. A nurse is preparing to administer verapamil to a client who is 2 days postmyocardial infarction. The nurse should monitor the client for which of the following outcomes as a therapeutic response to the medication?

• A. Decreased blood pressure
• B. Decreased anginal pain
• C. Decreased heart rate
• D. Decreased anxiety

Correct answer: B

Rationale: The correct answer is B: Decreased anginal pain. Verapamil is a calcium channel blocker used to relieve angina by reducing myocardial oxygen demand. Monitoring for decreased anginal pain is essential as it indicates a therapeutic response to the medication. Choices A, C, and D are incorrect as verapamil's primary goal in this context is not to decrease blood pressure, heart rate, or anxiety.

Similar Questions