Nursing Elites

1. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?

• A. I will make sure my medications are enteric-coated.
• B. My stoma will drain liquid continuously.
• C. I will change my pouch system every two weeks.
• D. My stoma size will stay the same after it heals.

Correct answer: B

Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.

2. In orienting new staff nurses to a pediatric intensive care unit, what is an important consideration in providing information to parents of a critically ill child?

• A. Making sure they receive complete information during each encounter
• B. Assessing parents' preferences regarding the amount of information
• C. Allowing parents to observe key aspects of their child's care
• D. Providing patient education brochures explaining ICU protocols

Correct answer: B

Rationale: Assessing parents' preferences about the amount of information is crucial because it allows for individualized care that respects their needs and emotional capacity during a stressful time. Choice A is not ideal as overwhelming parents with complete information during each encounter may not align with their preferences. Choice C, while valuable, may not always be feasible or appropriate due to privacy concerns or medical procedures. Choice D, providing brochures, may not address the specific needs or preferences of each set of parents, making it less effective than assessing individual preferences.

3. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?

• A. Urinary output of 40 mL/hr
• B. Respiratory rate of 10 breaths per minute
• C. Absent deep tendon reflexes
• D. Blood pressure of 150/90 mm Hg

Correct answer: B

Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention. Urinary output of 40 mL/hr (Choice A) is within the normal range for a client receiving magnesium sulfate. Absent deep tendon reflexes (Choice C) are an expected finding due to the medication's effect on neuromuscular excitability. A blood pressure of 150/90 mm Hg (Choice D) is slightly elevated but not a priority concern compared to severe respiratory depression.

4. A client with multiple sclerosis reports diplopia. Which of the following actions should the nurse take?

• A. Encourage the client to focus on a distant object.
• B. Apply a warm compress to the client’s eyes.
• C. Recommend alternating eye patches during the day.
• D. Administer artificial tears.

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with multiple sclerosis reporting diplopia is to recommend alternating eye patches during the day. This strategy can help relieve diplopia (double vision) by allowing each eye to rest alternately, reducing eye strain. Encouraging the client to focus on a distant object (Choice A) is not an appropriate intervention for diplopia in this case. Applying a warm compress to the client's eyes (Choice B) and administering artificial tears (Choice D) are not effective interventions for diplopia associated with multiple sclerosis.

5. A client at 28 weeks of gestation is experiencing preterm labor. Which of the following medications should the nurse plan to administer?

• A. Oxytocin
• B. Nifedipine
• C. Dinoprostone
• D. Misoprostol

Correct answer: B

Rationale: Nifedipine is the correct choice in this scenario. It is a calcium channel blocker that helps suppress uterine contractions and halt preterm labor. Nifedipine is commonly used to manage preterm labor in pregnant women by relaxing the smooth muscle of the uterus. Oxytocin (Choice A) is used to induce or augment labor, not to inhibit contractions. Dinoprostone (Choice C) and Misoprostol (Choice D) are prostaglandins used for cervical ripening and induction of labor, not for stopping preterm labor.

Similar Questions