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 assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

• A. Apply oxygen at 10 L/min via face mask
• B. Position the client on their side
• C. Call for a Cesarean delivery
• D. Administer oxytocin

Correct answer: B

Rationale: Late decelerations indicate uteroplacental insufficiency, and the priority nursing action is to improve placental perfusion. Positioning the client on their side, particularly the left side, can enhance blood flow to the placenta and fetus by reducing pressure on the vena cava and increasing cardiac output. Applying oxygen, although helpful, is not the initial priority in this situation. Calling for a Cesarean delivery is not warranted unless other interventions fail to correct the late decelerations. Administering oxytocin can worsen the condition by increasing uterine contractions, exacerbating fetal distress.

3. A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

• A. Pupils constrict when shifting gaze from near to far
• B. Pupils constrict when shifting gaze from far to near
• C. Lack of change in pupil size when shifting gaze from near to far
• D. Lack of change in pupil size when shifting gaze from far to near

Correct answer: D

Rationale: Pupil accommodation problems are indicated by the lack of change in size when shifting gaze from far to near. The correct answer is D because in pupil accommodation, the pupils should constrict when shifting gaze from far to near in order to adjust for near vision. Choices A and B describe normal responses of pupil constriction when shifting gaze, which do not indicate a problem. Choice C is incorrect as it describes a normal response of pupil size change when shifting gaze from near to far.

4. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?

• A. Educate the client about their current medical diagnosis.
• B. Refer the client to a meal delivery program.
• C. Identify environmental hazards in the home.
• D. Arrange transportation for the client to follow-up appointments.

Correct answer: C

Rationale: Identifying environmental hazards in the client's home is the priority during the initial visit with an older adult living alone. This action is crucial to prevent accidents, falls, and ensure the client's safety. While educating the client about their medical diagnosis, referring them to a meal delivery program, and arranging transportation for follow-up appointments are essential, addressing environmental hazards takes precedence as it directly impacts the client's immediate safety and well-being.

5. What are the early signs of a pulmonary embolism?

• A. Chest pain, shortness of breath, and tachycardia
• B. Fever, nausea, and vomiting
• C. Cough, cyanosis, and fatigue
• D. Abdominal pain and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain, shortness of breath, and tachycardia. These are classic early signs of a pulmonary embolism. Chest pain may be sudden and sharp, worsened by deep breathing or coughing. Shortness of breath can be sudden and severe. Tachycardia (rapid heart rate) is another common symptom. Choices B, C, and D are incorrect as they do not represent typical early signs of a pulmonary embolism.

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