Nursing Elites

1. Which of the following statements indicates the client understands the colostomy care instructions?

• A. I will change the colostomy bag once a week.
• B. I will avoid eating high-fiber foods.
• C. I will clean around the stoma with mild soap and water.
• D. I will apply lotion to the skin around the stoma.

Correct answer: C

Rationale: The correct answer is C. Cleaning around the stoma with mild soap and water is crucial for colostomy care as it helps prevent infection and skin irritation. Changing the colostomy bag frequency, dietary modifications, or applying lotion are not primary aspects of stoma care. Proper cleaning around the stoma helps maintain hygiene and prevents complications, making it a key component of caring for a colostomy.

2. A client with a new prescription for a dry-powder inhaler (DPI) is receiving teaching from a healthcare provider. Which of the following statements indicates an understanding of the teaching?

• A. I will shake the inhaler before use.
• B. I will take the medication with food.
• C. I will inhale the medication quickly.
• D. I will use a spacer with the inhaler.

Correct answer: C

Rationale: Choosing option C, 'I will inhale the medication quickly,' demonstrates an understanding of DPI use. Inhaling the medication quickly ensures effective delivery of the dry powder to the lungs, maximizing its therapeutic effects. Options A, B, and D are incorrect as shaking the DPI, taking it with food, and using a spacer are not recommended practices for DPI administration. Shaking a DPI can cause clumping or uneven dispersion of the medication, taking it with food may not affect its efficacy but can increase the risk of side effects, and using a spacer is not necessary for DPIs which are breath-actuated and do not require coordination with inhalation through a spacer.

3. A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following interventions should the healthcare provider include?

• A. Massage the ulcer
• B. Apply a heating pad
• C. Reposition the client every 2 hours
• D. Use alcohol-based cleansers

Correct answer: C

Rationale: Repositioning the client every 2 hours is a crucial intervention in the management of pressure ulcers. This action helps redistribute pressure, reducing the risk of further skin breakdown and promoting wound healing. Massaging the ulcer can cause further damage to the skin and underlying tissues. Applying a heating pad can increase the risk of skin breakdown and should be avoided. Alcohol-based cleansers are too harsh for pressure ulcers and can irritate the skin, potentially delaying healing.

4. A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?

• A. Avoid beverages containing caffeine
• B. Take a sleep medication regularly at bedtime
• C. Watch television for 30 minutes in bed to relax before falling asleep
• D. Advise the client to take several naps during the day

Correct answer: A

Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.

5. A client is postoperative following abdominal surgery. Which of the following actions should be taken to prevent respiratory complications?

• A. Instruct the client to exhale into an incentive spirometer
• B. Reposition the client every 8 hours
• C. Assist the client with early ambulation
• D. Maintain the client on bed rest for the first 48 hours

Correct answer: C

Rationale: Assisting the client with early ambulation is crucial in preventing respiratory complications after abdominal surgery. Early ambulation helps to prevent conditions like atelectasis and pneumonia by promoting lung expansion and preventing pooling of respiratory secretions. It also aids in improving circulation, reducing the risk of deep vein thrombosis, and enhancing overall recovery. Instructing the client to exhale into an incentive spirometer (Choice A) is beneficial for lung expansion but is more focused on respiratory therapy rather than preventing complications. Repositioning the client every 8 hours (Choice B) is important for preventing pressure ulcers but is not directly related to preventing respiratory complications. Maintaining the client on bed rest for the first 48 hours (Choice D) can lead to complications such as atelectasis, pneumonia, and deep vein thrombosis due to decreased lung expansion and mobility.

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