Nursing Elites

1. The nurse is caring for a client with a newly placed colostomy. Which statement by the client indicates a need for additional teaching?

• A. I will need to change the colostomy bag every day.
• B. I should avoid foods that can cause gas, such as beans and carbonated drinks.
• C. I need to empty the colostomy bag when it is one-third to one-half full.
• D. I will need to take care of the skin around the stoma to prevent irritation.

Correct answer: A

Rationale: The correct answer is A. Changing the colostomy bag every day is not necessary; it should be changed as needed, usually every 3-7 days. This statement indicates a need for additional teaching as frequent changes can irritate the skin and are not typically required. Choices B, C, and D are all correct statements regarding colostomy care. Avoiding gas-producing foods, emptying the bag when it is one-third to one-half full, and taking care of the skin around the stoma are all essential aspects of colostomy care to prevent complications and maintain skin integrity.

2. The patient has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?

• A. Assess surfaces exposed to the edges of the cast for pressure areas.
• B. Keep the patient's blood pressure low to prevent overperfusion of tissue.
• C. Allow turning in bed to prevent complications.
• D. Encourage the patient's dietary intake to maintain hydration.

Correct answer: A

Rationale: To prevent skin impairment in a patient with a cast, the nurse should assess surfaces exposed to the edges of the cast for pressure areas. This is important to prevent pressure ulcers or skin breakdown. Keeping the patient's blood pressure low (Choice B) is not directly related to preventing skin impairment in this scenario. Allowing turning in bed (Choice C) is essential for preventing complications like pressure ulcers and is not contraindicated. Encouraging the patient's dietary intake (Choice D) to maintain hydration is not directly related to preventing skin impairment associated with a cast.

3. A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication is not an option for managing pain. Which of the following is an appropriate response by the nurse?

• A. I'm sure it will work if you just give it a chance.
• B. You may take any herbal remedies you bring from home.
• C. Why do you think pain medication is not going to help you?
• D. Would you like me to give you a back massage?

Correct answer: D

Rationale: In this scenario, the client has expressed that pain medication is not an option for managing pain. Offering alternative pain relief options like a back massage is appropriate because it respects the client's preferences and provides a non-pharmacological intervention to help alleviate pain. Choices A, B, and C are not as suitable: A may come across as dismissive of the client's decision, B may not be safe as herbal remedies can interact with medical treatments, and C focuses more on questioning the client's decision rather than providing immediate comfort.

4. An elderly client who requires frequent monitoring fell and fractured a hip. Which LPN/LVN is at greatest risk for a malpractice judgment?

• A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
• B. The nurse assigned to care for the client who was at lunch at the time of the fall.
• C. The nurse who transferred the client to the chair when the fall occurred.
• D. The charge nurse who completed rounds 30 minutes before the fall occurred.

Correct answer: C

Rationale: The nurse who transferred the client to the chair when the fall occurred is directly involved in the event that led to the injury. Improper transfer techniques or lack of appropriate precautions during the transfer could have contributed to the fall and subsequent fracture of the hip. This direct involvement makes this nurse the one at greatest risk for a malpractice judgment. Choices A, B, and D are not as directly linked to the event that caused the injury. While poor nursing notes could be a factor, it is the immediate action of transferring the client that has a more direct impact on the client's fall and subsequent injury.

5. A client is being taught how to care for their tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy site with hydrogen peroxide daily.
• C. Change the tracheostomy tube weekly.
• D. Apply ointment around the tracheostomy site.

Correct answer: A

Rationale: The correct instruction is to use tracheostomy covers when outdoors. Tracheostomy covers serve to protect the airway from environmental contaminants, reducing the risk of infection. Choice B is incorrect because hydrogen peroxide can be irritating to the skin and is not recommended for cleaning the tracheostomy site. Choice C is incorrect as tracheostomy tubes should not be routinely changed weekly unless there is a specific medical indication. Changing it without a need can introduce infection or damage the stoma. Choice D is incorrect as applying ointment around the tracheostomy site can lead to occlusion of the stoma and interfere with breathing.

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