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. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do?

• A. Tell her family that probably she can’t hear them
• B. Talk loudly so that Wendy can hear you
• C. Tell her family who are in the room not to talk
• D. Speak softly then hold her hands gently

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.

3. Which of the following statements is correct about MyPlate?

• A. Canned fruit can be considered part of the fruit group
• B. Soymilk is considered part of the dairy group
• C. Beans and peas are considered part of both the protein group and the vegetable group
• D. Cream cheese and butter are not part of the dairy group

Correct answer: C

Rationale: According to the MyPlate guide, beans and peas are classified as part of both the protein and vegetable groups due to their high protein content and the nutrients they share with vegetables. This makes Choice C correct. Choice A is incorrect as canned fruit can be part of the fruit group if it's canned in water or 100% fruit juice. Soymilk is considered part of the dairy group, making Choice B incorrect. While cream cheese and butter are dairy products, they are not part of the dairy group on MyPlate because they contain little to no calcium, making Choice D incorrect.

4. How is the stomach protected from damage by gastric acid?

• A. enzymes present in the stomach
• B. a protective bacteria in the stomach
• C. bicarbonate present in the stomach
• D. the mucus lining of the stomach

Correct answer: D

Rationale: The correct answer is D. The stomach is protected from gastric acid by a thick mucus lining that acts as a physical barrier, preventing the acid from eroding the stomach walls. Enzymes in the stomach help with digestion but do not play a significant role in protecting the stomach from acid damage, so choice A is incorrect. While some bacteria in the stomach can be beneficial, they do not primarily protect the stomach from gastric acid, making choice B incorrect. Bicarbonate, a base, can neutralize acid, but it is not the primary defense mechanism against gastric acid in the stomach, so choice C is also incorrect.

5. An appropriate nursing diagnosis for clients in the acute manic phase of bipolar disorder is:

• A. Risk for injury directed to self
• B. Risk for injury directed to others
• C. Impaired nutrition less than body requirements
• D. Ineffective individual coping

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.

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