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 provider is planning care for a client who has a new prescription for a high-fiber diet. Which of the following foods should the healthcare provider recommend?

• A. White bread
• B. Canned fruit
• C. Cheese
• D. Brown rice

Correct answer: D

Rationale: Brown rice is a whole grain that is high in fiber, making it an excellent choice for a high-fiber diet. Foods like white bread, canned fruit, and cheese are typically low in fiber and would not be the best recommendation for a high-fiber diet. White bread is processed and lacks the fiber content found in whole grains like brown rice. Canned fruit, although containing some fiber, often has added sugars and lower fiber content compared to fresh fruits. Cheese is a dairy product that is generally low in fiber and not a significant source of dietary fiber compared to whole grains.

3. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

4. What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?

• A. Flush the feeding tube with water before and after feedings.
• B. Elevate the head of the bed to 30-45 degrees during feedings.
• C. Administer the feeding slowly.
• D. Check the client's weight daily.

Correct answer: B

Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.

5. A client with hyperlipidemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of foods high in saturated fats.
• B. I should decrease my intake of foods high in cholesterol.
• C. I should increase my intake of foods high in trans fats.
• D. I should decrease my intake of foods high in fiber.

Correct answer: B

Rationale: The correct answer is B. In hyperlipidemia management, decreasing the intake of foods high in cholesterol is crucial to improve lipid levels and reduce the risk of cardiovascular diseases. Choices A and C are incorrect as increasing intake of saturated fats or trans fats can raise cholesterol levels, worsening the condition. Choice D is incorrect because decreasing intake of foods high in fiber is not recommended as fiber-rich foods are beneficial for heart health, which is important in managing hyperlipidemia.

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