Nursing Elites

1. A nurse is caring for a client with a new colostomy. What is the nurse's responsibility regarding stoma care?

• A. Educate the client on how to care for the stoma independently.
• B. Contact the stoma nurse to assist the client with care.
• C. Delegate the care of the stoma to a nursing assistant.
• D. Wait until the next shift to address the stoma care.

Correct answer: B

Rationale: The correct answer is to contact the stoma nurse to assist the client with care. Stoma nurses are specially trained to provide guidance on stoma care, especially for clients with new ostomies. Instructing the client to care for the stoma independently (Choice A) may not be appropriate initially as they may need professional guidance. Delegating the care of the stoma to a nursing assistant (Choice C) is not recommended as specialized care is required. Waiting until the next shift (Choice D) is not ideal as stoma care should not be delayed.

2. A client who has been having frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse add to the client's plan of care?

• A. Apply restraints
• B. Use soft wristbands
• C. Wrap blankets around side rails
• D. Administer sedatives

Correct answer: C

Rationale: The correct action the nurse should add to the client's plan of care is to wrap blankets around side rails. This helps prevent injury during seizures by providing a cushioned surface against the hard rails. Applying restraints (Choice A) is not recommended as it can cause harm during a seizure. Using soft wristbands (Choice B) may not provide adequate protection against injury. Administering sedatives (Choice D) is not typically indicated for managing tonic-clonic seizures as they require specific anti-seizure medications.

3. A nurse is caring for a client who is postoperative and has compression stockings. Which action should the nurse take?

• A. Check the stockings for wrinkles
• B. Apply the stockings while the client is sitting in a chair
• C. Measure the size of the client's foot
• D. Remove the stockings once each day

Correct answer: A

Rationale: The correct action for the nurse to take is to check the stockings for wrinkles. This is important to ensure that the stockings are applied correctly without any folds or wrinkles, which can hinder proper circulation and compression. Option B is incorrect because compression stockings should be applied with the client lying down, not sitting in a chair. Option C is unnecessary as the size of the client's foot is unlikely to change postoperatively. Option D is incorrect as compression stockings are usually worn continuously except for specific care needs.

4. What are the key considerations when administering medication via a nasogastric (NG) tube?

• A. Checking tube placement before administration
• B. Administering medication in liquid form whenever possible
• C. Crushing tablets and mixing them with water if needed
• D. Flushing the NG tube with water before and after medication

Correct answer: A

Rationale: The correct answer is A: Checking tube placement before administration. This is a crucial step to ensure that the medication reaches the stomach safely and does not end up in the lungs, which can lead to serious complications. Choice B is incorrect as not all medications can be administered in liquid form. Choice C is incorrect because crushing tablets can alter their effectiveness or cause harm. Choice D is incorrect as flushing the NG tube with water is not a standard practice before administering medication, unless specified by healthcare provider instructions.

5. A nurse is preparing to administer medications to four clients. The nurse should administer medications to which client first?

• A. A client who has pneumonia and a WBC count of 11,500/mm3 prescribed piperacillin
• B. A client who has renal failure and a serum potassium of 5.8 mEq/L prescribed sodium polystyrene sulfonate
• C. A client who is post-coronary artery bypass graft (CABG) prescribed atorvastatin
• D. A client who has anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa

Correct answer: B

Rationale: The correct answer is B. The client with renal failure and high potassium levels requires immediate attention because hyperkalemia can lead to life-threatening cardiac complications. Administering sodium polystyrene sulfonate helps lower the potassium levels. Choice A, the client with pneumonia and a high WBC count, although important, does not present an immediate life-threatening condition. Choice C, the post-CABG client prescribed atorvastatin, and Choice D, the client with anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa, do not require immediate intervention compared to managing hyperkalemia in a client with renal failure.

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