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 diagnosis of COPD is being taught about dietary management. Which of the following statements should be included in the teaching?

• A. You should increase your intake of high-calorie foods.
• B. You should decrease your intake of high-protein foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of high-fiber foods.

Correct answer: A

Rationale: The correct statement to include in the teaching for a client with a new diagnosis of COPD is that they should increase their intake of high-calorie foods. This is important to help maintain energy levels and manage weight. COPD can lead to increased energy expenditure due to the increased work of breathing, making it crucial to consume adequate calories for energy. High-calorie foods can help prevent weight loss and support overall nutritional status in COPD patients. Choice B is incorrect because high-protein foods are important for maintaining muscle mass in COPD patients. Choice C is incorrect as there is no need to avoid foods that contain lactose unless the client is lactose intolerant. Choice D is incorrect as increasing high-fiber foods may exacerbate symptoms like bloating and gas in COPD patients.

3. A client with a seizure disorder is under the care of a nurse. Which of the following precautions should the nurse include in the plan?

• A. Place a padded tongue depressor at the bedside.
• B. Keep the bed in the lowest position.
• C. Restrain the client during a seizure.
• D. Keep the lights dim in the client's room.

Correct answer: B

Rationale: Keeping the bed in the lowest position is crucial for ensuring the safety of the client during a seizure. Lowering the bed reduces the risk of injury if the client falls during a seizure episode. It is important not to restrain the client during a seizure as it can lead to further injury. Placing a padded tongue depressor at the bedside is not appropriate and can pose a risk of injury if used incorrectly. Keeping the lights dim in the client's room is not directly related to safety during a seizure and is not a standard precaution.

4. When teaching a client about the proper use of a cane, which of the following instructions should be included?

• A. Hold the cane on the weaker side.
• B. Move the cane forward first.
• C. Keep the cane 12 inches away from the body.
• D. Use the cane for support only when climbing stairs.

Correct answer: B

Rationale: When using a cane, it is crucial to move the cane forward first to provide support and enhance balance. Advancing the cane before the weaker or stronger leg helps widen the base of support, thereby improving stability during ambulation. Keeping the cane too far or too close to the body can affect its supportive function. Moreover, utilizing the cane solely for stair climbing limits its overall utility in maintaining balance and stability during regular walking.

5. What action is required by law when preparing to administer a controlled substance?

• A. Verify the client’s identification using two identifiers.
• B. Document the medication administration in the client’s chart immediately.
• C. Return any unused portion of the medication to the pharmacy.
• D. Have a second nurse witness the disposal of any unused portion.

Correct answer: D

Rationale: Having a second nurse witness the disposal of any unused portion of a controlled substance is a legal requirement to ensure proper disposal, prevent diversion, and maintain accountability. This practice helps in reducing the risk of misuse or unauthorized access to controlled substances, enhancing patient safety, and complying with legal regulations and standards.

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