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 healthcare professional is assessing a client who has deep-vein thrombosis (DVT). Which of the following findings should the professional expect?

• A. Swelling of the affected limb.
• B. Diminished peripheral pulses.
• C. Coolness of the affected limb.
• D. Redness and warmth of the affected limb.

Correct answer: D

Rationale: Redness and warmth of the affected limb are classic signs of deep-vein thrombosis (DVT) due to inflammation and increased blood flow. These symptoms occur as a result of the blood clot obstructing normal blood flow and causing localized inflammation in the affected limb. Swelling of the affected limb, diminished peripheral pulses, and coolness are not typically associated with DVT. Swelling can be present but is often accompanied by the characteristic redness and warmth. Diminished pulses and coolness are more indicative of arterial insufficiency rather than venous thrombosis.

3. A nurse is providing discharge teaching to a client who has a prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take your pulse before taking the medication.
• B. Take the medication with an antacid.
• C. Double the dose if you miss one.
• D. Take the medication with a high-fiber meal.

Correct answer: A

Rationale: The correct answer is A: 'Take your pulse before taking the medication.' When administering digoxin, it is crucial to monitor the pulse rate because digoxin can cause bradycardia (slow heart rate). Checking the pulse helps in assessing the heart rate before taking the medication, as bradycardia is a common side effect of digoxin. Choice B is incorrect because digoxin should not be taken with antacids, as they can reduce its absorption. Choice C is incorrect; the dose should never be doubled if a dose is missed. Choice D is incorrect because taking digoxin with a high-fiber meal can also affect its absorption. Therefore, the essential instruction for the client is to monitor the pulse before taking digoxin.

4. In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?

• A. A Glasgow Coma Scale score of 13
• B. Clear fluid leaking from the nose
• C. Nausea and vomiting
• D. Anisocoria

Correct answer: B

Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.

5. A client with a new diagnosis of hypertension is being taught about lifestyle changes. Which of the following statements should the nurse include in the teaching?

• A. You should limit your alcohol intake to no more than one drink per day.
• B. You should increase your sodium intake to at least 2,300 mg per day.
• C. You should limit your physical activity to avoid increasing your blood pressure.
• D. You should avoid eating dairy products to help lower your blood pressure.

Correct answer: A

Rationale: The correct statement to include in teaching a client with hypertension is to limit alcohol intake to no more than one drink per day. Excessive alcohol consumption can raise blood pressure and lead to complications. Increasing sodium intake, limiting physical activity, and avoiding dairy products are not recommended for managing hypertension. Clients with hypertension should follow a heart-healthy diet low in sodium, engage in regular physical activity, and monitor their blood pressure regularly to control hypertension effectively.

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