Nursing Elites

1. A client with a newly created ileostomy has not had ostomy output for the past 12 hours and reports worsening nausea. What is the nurse's priority action?

• A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse
• B. Report signs and symptoms of obstruction to the health care provider
• C. Encourage the client to mobilize to enhance mobility
• D. Contact the health care provider to obtain a swab of the stoma for culture

Correct answer: B

Rationale: The nurse's priority action in this situation is to report signs and symptoms of possible obstruction to the healthcare provider. Lack of ostomy output and worsening nausea can indicate a potential obstruction, which requires immediate attention and intervention to prevent complications.

2. A client with a history of chronic alcohol use is admitted with confusion and an unsteady gait. Which deficiency should the nurse suspect?

• A. Thiamine (Vitamin B1)
• B. Cyanocobalamin (Vitamin B12)
• C. Folic acid
• D. Vitamin D

Correct answer: A

Rationale: The correct answer is Thiamine (Vitamin B1). Chronic alcohol use can lead to thiamine deficiency, which can result in neurological symptoms such as confusion and an unsteady gait. Thiamine is essential for proper brain function and nerve conduction, and its deficiency is common in individuals with alcohol use disorder. Cyanocobalamin (Vitamin B12) deficiency can also present with neurological symptoms, but in this case, the patient's history of chronic alcohol use points more towards thiamine deficiency. Folic acid deficiency typically presents with symptoms like fatigue and megaloblastic anemia. Vitamin D deficiency is associated with bone health issues rather than neurological symptoms.

3. A client with heart failure is prescribed furosemide (Lasix). Which instruction should the nurse include in the client's teaching plan?

• A. Take the medication before bedtime.
• B. Report any weight gain of more than 2 pounds in a day.
• C. Increase your intake of high-sodium foods.
• D. Limit your fluid intake to less than 1 liter per day.

Correct answer: B

Rationale: In heart failure, fluid retention is a concern. Furosemide helps manage this by promoting diuresis. Instructing the client to report weight gain exceeding 2 pounds in a day is crucial as it can indicate fluid accumulation, prompting timely intervention to prevent worsening heart failure symptoms and complications.

4. After performing a paracentesis on a client with ascites, 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?

• A. Pedal pulses.
• B. Breath sounds.
• C. Gag reflex.
• D. Vital signs.

Correct answer: D

Rationale: Following a paracentesis where a significant amount of fluid is removed, it is crucial to monitor the client's vital signs. This helps in detecting any signs of hypovolemia, such as changes in blood pressure, heart rate, and respiratory rate, which could indicate complications post-procedure. Monitoring the vital signs allows for prompt intervention if there are any deviations from the baseline values.

5. A client with a history of diabetes mellitus is admitted with a foot ulcer. The nurse should recognize that which intervention is most critical in promoting healing of the foot ulcer?

• A. Strict control of blood glucose levels.
• B. Regular dressing changes with sterile technique.
• C. Application of antibiotic ointment.
• D. Hydrotherapy treatment daily.

Correct answer: A

Rationale: In diabetic clients with foot ulcers, strict control of blood glucose levels is essential for promoting wound healing. High blood glucose levels can impair circulation and compromise the body's ability to fight infection, delaying the healing process. By maintaining optimal blood glucose levels, the client's overall health and wound healing potential are improved.

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