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. In which of the following conditions does a person need to sit, stand, or use multiple pillows when lying down?

• A. Orthopnea
• B. Dyspnea
• C. Eupnea
• D. Apnea

Correct answer: A

Rationale: The correct answer is Orthopnea. Orthopnea is a medical condition in which a person has difficulty breathing while lying down. To alleviate this difficulty, the person may need to sit, stand, or use multiple pillows. On the other hand, Dyspnea refers to general shortness of breath which is not specifically related to the position of the body. Eupnea is the term for normal, unlabored breathing, and Apnea is a condition characterized by the cessation of breathing. Thus, none of these other choices directly relate to the need to adjust body position or use aids like multiple pillows to breathe comfortably when lying down.

3. The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:

• A. Narrowing of the pulse pressure
• B. Vomiting
• C. Periorbital edema
• D. A positive Kernig's sign

Correct answer: C

Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.

4. Each statement is true of water-soluble vitamins, except one. Which is it?

• A. Act as coenzymes
• B. Deficiencies develop rapidly
• C. Daily intake is necessary
• D. Absorbed in the jejunum

Correct answer: B

Rationale: The correct answer is B. Water-soluble vitamins do not develop deficiencies rapidly because the body does not store them for long periods. They must be obtained through food constantly. Choice A is correct because water-soluble vitamins often act as coenzymes in various metabolic reactions. Choice C is correct as daily intake of water-soluble vitamins is necessary since they are not stored in the body. Choice D is incorrect as water-soluble vitamins are absorbed primarily in the small intestine, particularly in the duodenum and ileum, not the jejunum.

5. Diego is undergoing blood transfusion of the first unit. The earliest signs of transfusion reactions are:

• A. Oliguria and jaundice
• B. Urticaria and wheezing
• C. Headache, chills, & fever
• D. Hypertension and flushing

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.

Similar Questions