Nursing Elites

1. A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?

• A. Albumin
• B. Calcium
• C. Sodium
• D. Potassium

Correct answer: A

Rationale: The correct answer is Albumin. Albumin is a protein made by the liver and is a key indicator of the body's protein status. Low levels of albumin can indicate inadequate protein intake or synthesis. Choices B, C, and D (Calcium, Sodium, and Potassium) are not direct indicators of protein uptake and synthesis. Calcium is related to bone health, Sodium to fluid balance, and Potassium to nerve and muscle function.

2. Water loss can occur from each, except one. Which is the exception?

• A. Respiratory inflammation
• B. Strenuous exercise
• C. Diarrhea
• D. Perspiration

Correct answer: D

Rationale: The correct answer is D, Perspiration. Water loss can occur through respiration inflammation, strenuous exercise, and diarrhea. Perspiration, also known as sweating, is a mechanism by which the body regulates temperature and eliminates some waste products, but it is not a cause of water loss. The body loses water through sweating, but this loss is mainly for cooling purposes, and it is not a primary mechanism for water loss like respiration, exercise, or diarrhea.

3. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

• A. Pink, moist, and slightly protruding from the abdomen
• B. Gray, moist, and slightly protruding from the abdomen
• C. Pink, dry, and slightly protruding from the abdomen
• D. Red, moist, and slightly protruding from the abdomen

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

4. Which test is used to monitor the degree of blood glucose control over a long period?

• A. Glucose tolerance test
• B. Glycated hemoglobin level
• C. Self-monitoring of blood glucose
• D. 24-hour urinary glucose excretion

Correct answer: B

Rationale: The correct answer is B, glycated hemoglobin level. The glycated hemoglobin (HbA1c) test measures the average blood glucose levels over the past 2-3 months, providing a long-term picture of glucose control. Choice A, the glucose tolerance test, measures how well your body processes glucose but is not specifically for long-term monitoring. Choice C, self-monitoring of blood glucose, involves daily testing by individuals, providing immediate rather than long-term information. Choice D, 24-hour urinary glucose excretion, measures the amount of glucose excreted in the urine over 24 hours and is not typically used for long-term monitoring of blood glucose control.

5. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:

• A. Percussion uses only one hand, while vibration uses both hands
• B. Percussion delivers cushioned blows to the chest with cupped palms, while vibration gently shakes secretions loose
• C. In both percussion and vibration, the hands are not on top of each other, and hand action is not in tune with the client's breath
• D. Percussion slaps the chest to loosen secretions, while vibration shakes the secretions along with the inhalation

Correct answer: D

Rationale: Chest percussion involves the use of rhythmic tapping to dislodge mucus from the lungs, facilitating its movement toward the larger airways where it can be expelled. This technique is particularly important in conditions where mucus retention is a significant risk factor for infection. The key difference between chest percussion and vibration is that percussion involves slapping the chest to loosen secretions, while vibration involves shaking the secretions along with the inhalation, aiding in moving the loosened secretions upwards for easier removal. Choices A, B, and C do not accurately describe the main difference between chest percussion and vibration, making them incorrect.

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