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 nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

• A. Discuss whether family members will assist with postoperative care
• B. Review the client's current home environment
• C. Identify the client's usual coping mechanisms
• D. Determine what the client knows about the surgery

Correct answer: D

Rationale: In the preoperative phase, determining what the client knows about the surgery is the priority. This action helps address misconceptions, provide necessary information, and ensure the client's understanding and cooperation. Choices A, B, and C are important aspects of preoperative care but assessing the client's knowledge about the surgery takes precedence to alleviate fears, enhance communication, and optimize outcomes.

3. A client with a history of seizures is admitted for monitoring. What should the nurse prioritize?

• A. Ensure the client is on seizure precautions.
• B. Educate the client about seizure triggers.
• C. Monitor for signs of an impending seizure.
• D. Initiate IV access for anti-seizure medication.

Correct answer: A

Rationale: The correct answer is to ensure the client is on seizure precautions. This is crucial in preventing injury during a seizure episode. While educating the client about seizure triggers (choice B) is important for long-term management, it is not the priority when the client is admitted for monitoring. Monitoring for signs of an impending seizure (choice C) is essential but does not address immediate safety concerns. Initiating IV access for anti-seizure medication (choice D) is not the priority unless a seizure occurs and medical intervention is needed.

4. A nurse at a provider's office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (SATA)

• A. Top fruits with yogurt
• B. Add cream to soups
• C. Increase fluids during meals
• D. Use milk instead of water in recipes

Correct answer: A

Rationale: Topping fruits with yogurt is the correct recommendation to increase calorie and protein intake for a client on chemotherapy who is losing weight. Yogurt is a good source of protein and adding it to fruits can provide additional calories as well. Choice B, adding cream to soups, may increase calorie intake but does not specifically address protein needs. Choice C, increasing fluids during meals, is important for hydration but does not directly address calorie and protein intake. Choice D, using milk instead of water in recipes, may increase calorie content but does not focus on increasing protein intake, which is essential for clients on chemotherapy.

5. A healthcare professional is caring for a client with impaired mobility. Which of the following support devices should the healthcare professional plan to use to prevent the client from developing plantar flexion contractures?

• A. Sheepskin heel pad
• B. Footboard
• C. Trochanter roll
• D. Abduction pillow

Correct answer: B

Rationale: A footboard is the correct choice to prevent plantar flexion contractures by maintaining proper alignment of the feet. Plantar flexion contractures involve the foot pointing downward, and a footboard helps keep the foot in a neutral position. Choice A, the sheepskin heel pad, is used for pressure ulcer prevention and comfort but does not specifically address plantar flexion contractures. Choice C, the trochanter roll, is used for hip positioning, not foot alignment. Choice D, the abduction pillow, is used to maintain proper positioning of the legs but does not directly address plantar flexion contractures.

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