Nursing Elites

1. All of the following are electrolytes except:

• A. chloride
• B. potassium
• C. sodium
• D. iron

Correct answer: D

Rationale: Iron is not an electrolyte; electrolytes like sodium, potassium, and chloride help maintain fluid balance and are critical for nerve and muscle function.

2. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

• A. Pink, moist, and slightly protruding from the abdomen
• B. Gray, moist, and slightly protruding from the abdomen
• C. Pink, dry, and slightly protruding from the abdomen
• D. Red, moist, and slightly protruding from the abdomen

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

3. A client who is breastfeeding is being taught diet modification by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should drink an 8-ounce glass of water each time my baby nurses.
• B. I should take a 1500-milligram iron supplement daily.
• C. I can eat a 2500-calorie daily diet to lose 1 lb per week.
• D. I can eat ounces of swordfish daily.

Correct answer: A

Rationale: The correct answer is A because drinking an 8-ounce glass of water each time the baby nurses helps maintain hydration and support milk production. Choice B is incorrect as the need for iron supplementation should be discussed with a healthcare provider. Choice C is incorrect as a 2500-calorie diet is not typically recommended for weight loss during breastfeeding. Choice D is incorrect as consuming high levels of swordfish is not advisable due to its mercury content, which can be harmful to the baby.

4. Through the client’s health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s blood pressure for accurate reading?

• A. 15 minutes
• B. 30 minutes
• C. 1 hour
• D. 5 minutes

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. A nurse is caring for a client following an appendectomy. The nurse verifies the postoperative prescription which reads, 'Discontinue NPO status; advance diet as tolerated.' Which of the following are appropriate for the nurse to offer the client? (SATA)

• A. Wheat toast
• B. Applesauce
• C. Applesauce, Chicken broth
• D. Chicken broth

Correct answer: C

Rationale: The correct answer is C: Applesauce and chicken broth. After an appendectomy, patients are typically started on a clear liquid diet before advancing to more solid foods. Applesauce and chicken broth are part of a low-residue diet that is easily digestible and gentle on the digestive system, making them suitable choices for a client following surgery. Wheat toast may be too heavy and fibrous initially, while other solid foods should be introduced gradually to prevent gastrointestinal upset.

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