Nursing Elites

1. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

• A. Change the appliance daily
• B. Clean the stoma once a day
• C. Avoid changing the appliance for a week
• D. Change the appliance twice each week

Correct answer: D

Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.

2. A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?

• A. Continue to monitor the fetal heart rate.
• B. Stop the oxytocin infusion.
• C. Perform a vaginal examination.
• D. Initiate an amnioinfusion.

Correct answer: A

Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.

3. A client with a serum albumin level of 3 g/dL has a pressure ulcer. What should the nurse do first?

• A. Monitor the client's fluid and electrolyte balance
• B. Consult a dietitian to improve the client's nutritional status
• C. Administer a protein supplement
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.

4. What are the complications of diabetic ketoacidosis?

• A. Electrolyte imbalance and dehydration
• B. Hypoglycemia and increased urination
• C. Kidney failure and respiratory distress
• D. Liver failure and hypertension

Correct answer: A

Rationale: The correct answer is A: Electrolyte imbalance and dehydration. Diabetic ketoacidosis can lead to imbalances in electrolytes such as potassium, sodium, and chloride, as well as dehydration due to excess urination and vomiting. These complications should be managed promptly with appropriate fluids and insulin. Choices B, C, and D are incorrect. Hypoglycemia and increased urination are not typical complications of diabetic ketoacidosis; kidney failure and respiratory distress may occur in severe cases but are not the primary complications. Liver failure and hypertension are not directly associated with diabetic ketoacidosis.

5. A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following findings should the nurse identify as an indication of impending death?

• A. Hypertension.
• B. Tachycardia.
• C. Cold extremities.
• D. Diaphoresis.

Correct answer: C

Rationale: Cold extremities are a critical sign of impending death as they indicate decreased circulation, leading to poor perfusion to the extremities. This phenomenon occurs as the body redirects blood flow to vital organs, preparing for the end of life. Hypertension and tachycardia are less likely to be seen in the terminal phase and are usually associated with other conditions like shock or sepsis. Diaphoresis, or excessive sweating, may occur in various situations but is not a specific indicator of impending death in this context.

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