Nursing Elites

1. A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?

• A. Stoma that is red and moist
• B. Purulent drainage from the stoma
• C. Stoma that is dry and purple
• D. Mild swelling around the stoma

Correct answer: C

Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.

2. A nurse is teaching a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?

• A. "You can take this medication with a full glass of water."
• B. "You should store this medication in the refrigerator."
• C. "Take one tablet every 5 minutes until the pain is relieved, up to three doses."
• D. "You should avoid eating foods high in sodium while taking this medication."

Correct answer: C

Rationale: The correct statement the nurse should include is to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is important to manage angina attacks effectively. Option A is incorrect because nitroglycerin sublingual tablets should not be taken with water. Option B is incorrect as nitroglycerin tablets should be stored in their original container at room temperature. Option D is incorrect because there is no specific instruction to avoid foods high in sodium while taking nitroglycerin sublingual tablets.

3. A healthcare provider is assessing a client who has bacterial meningitis. Which of the following findings should the healthcare provider expect?

• A. Nuchal rigidity.
• B. Flaccid paralysis.
• C. Bradycardia.
• D. Hypothermia.

Correct answer: A

Rationale: Nuchal rigidity is a classic sign of bacterial meningitis and indicates inflammation of the meninges. It is characterized by neck stiffness and pain upon neck flexion. Flaccid paralysis (Choice B) is not typically associated with bacterial meningitis but rather conditions like Guillain-Barre syndrome. Bradycardia (Choice C) and hypothermia (Choice D) are not commonly seen in bacterial meningitis; instead, patients may present with fever, tachycardia, and signs of systemic inflammation.

4. A nurse is providing teaching to a client who has a new prescription for albuterol. Which of the following client statements indicates an understanding of the teaching?

• A. I will use this medication to prevent an asthma attack.
• B. I will use this medication for shortness of breath during an asthma attack.
• C. I will take this medication with my daily vitamins.
• D. I will take this medication at bedtime to prevent an asthma attack.

Correct answer: B

Rationale: The correct answer is B because albuterol is used to treat shortness of breath during an asthma attack. Choice A is incorrect as albuterol is a rescue medication used during an asthma attack, not for prevention. Choice C is incorrect as albuterol should not be taken with daily vitamins. Choice D is incorrect as albuterol is not typically taken at bedtime for asthma prevention.

5. When administering an incorrect dose of medication, which facts related to the incident report should the nurse document in the client's medical record?

• A. Time the medication was given
• B. The client's response to the medication
• C. The dose that was administered
• D. Reason for the error

Correct answer: A

Rationale: The nurse should document the time the medication was given in the client's medical record when administering an incorrect dose. This information is crucial for tracking the sequence of events leading to the error. Choice B, the client's response to the medication, is important for monitoring the client's condition post-administration but may not be directly linked to the incident report. Choice C, documenting the dose that was administered, is relevant but does not provide insights into the timing of events. Choice D, detailing the reason for the error, should be included in the incident report but may not need to be documented in the client's medical record.

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