Nursing Elites

1. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:

• A. Increase the irrigating solution flow rate when abdominal cramps is felt
• B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
• C. Position client in semi-Fowler
• D. Hang the solution 18 inches above the stoma

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. A client is on a 2,000-calorie American Diabetes Association (ADA) diet and substitutes whole milk with skim milk. Which of the following items can the client add to the oatmeal on his breakfast tray?

• A. One 1/8 teaspoon of salt
• B. One ounce of raisins
• C. One tablespoon of low-fat margarine
• D. One teaspoon of brown sugar

Correct answer: B

Rationale: The correct answer is one ounce of raisins. Raisins are a healthy option to add to oatmeal as they provide natural sweetness without added sugars. They are a good source of fiber and essential nutrients. Option A, one 1/8 teaspoon of salt, is not necessary for flavoring oatmeal. Option C, one tablespoon of low-fat margarine, may add unnecessary fat to the meal. Option D, one teaspoon of brown sugar, adds extra sugar, which should be limited in a diabetes-friendly diet.

3. Which condition is an example of a potential cause of gastritis?

• A. bile reflux
• B. low salt intake
• C. hypophosphatasia
• D. gallstones

Correct answer: A

Rationale: Bile reflux is a potential cause of gastritis as it can irritate the stomach lining when bile backs up into the stomach. Choices B, C, and D do not directly cause gastritis. Low salt intake is not a common cause of gastritis. Hypophosphatasia is a rare genetic disorder affecting bone development, not the stomach. Gallstones, while related to the gallbladder, are not a direct cause of gastritis.

4. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

• A. Instruct the client to observe strict bed rest
• B. Check for epidural catheter drainage
• C. Administer analgesia through the epidural catheter as prescribed
• D. Assess respiratory rate carefully

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

5. What is the absorbable unit of a protein?

• A. Amino acid
• B. Pepsin
• C. Glucose
• D. Sucrose

Correct answer: A

Rationale: Amino acids are the correct answer because they are the building blocks of proteins that the body absorbs after digestion. Pepsin, choice B, is incorrect as it is an enzyme that aids in the digestion of proteins, not the absorbable unit of them. Choices C and D, glucose and sucrose, are wrong because they are types of sugars, not proteins.

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