Nursing Elites

1. When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma?

• A. Antiseptic cream
• B. Petroleum jelly
• C. Cornstarch
• D. Stomadhesive

Correct answer: D

Rationale: The correct answer is 'Stomadhesive.' Stomadhesive is a protective barrier used around the stoma to prevent skin irritation and to secure the colostomy bag. This preparation helps to maintain skin integrity and prevent complications such as skin breakdown. Antiseptic cream (Choice A) is not typically used around the stoma as it can irritate the skin. Petroleum jelly (Choice B) is also not recommended as it can interfere with the adhesive properties of the colostomy appliance. Cornstarch (Choice C) is not suitable for application around the stoma as it can promote moisture and lead to skin irritation.

2. A client who is receiving chemotherapy has developed stomatitis. Which instruction should the nurse provide the UAP who is assisting with the care of this client?

• A. Keep the room environment free of unpleasant odors
• B. Gather supplies for protective environmental precautions
• C. Assist the client with feeding at meal times
• D. Provide gentle and meticulous mouth care

Correct answer: D

Rationale: Providing gentle and meticulous mouth care is critical for a client with stomatitis as it helps prevent further irritation and infection of the mucous membranes. Keeping the room environment free of unpleasant odors (Choice A) is important for the client's comfort but not directly related to managing stomatitis. Gathering supplies for protective environmental precautions (Choice B) is not relevant to addressing stomatitis. Assisting the client with feeding at meal times (Choice C) is important for overall care but does not specifically target the care needed for stomatitis.

3. For an older postoperative client with the nursing diagnosis 'impaired mobility related to fear of falling,' which desired outcome best directs the nurse's actions for the client?

• A. The client will ambulate with assistance every 4 hours
• B. The physical therapist will instruct the client in the use of a walker
• C. The client will use self-affirmation statements to decrease fear
• D. The nurse will place a gait belt on the client prior to ambulation

Correct answer: C

Rationale: Encouraging the client to use self-affirmation statements is the most appropriate desired outcome in this scenario. By utilizing self-affirmation statements, the client can address their fears directly and build confidence, which can ultimately lead to a reduction in fear of falling. While ambulating with assistance (choice A) is important, the focus here is on addressing the fear itself. Instructing the client in the use of a walker (choice B) and placing a gait belt on the client (choice D) are interventions that may be helpful but do not directly address the client's fear of falling.

4. The nurse and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the nurse implement?

• A. Demonstrate to the UAP how to approach the client from the client's left side
• B. Ask the UAP to leave the room and assess the client's body for bruising
• C. Carefully observe the interaction between the client and family members
• D. Instruct the UAP to protect the client's left side when transferring to a chair

Correct answer: A

Rationale: The correct action for the nurse to implement is to demonstrate to the UAP how to approach the client from the client's left side. Approaching the client from the neglected side (left side) can help in retraining the brain and improving awareness of the affected side, which is crucial in the management of neglect syndrome. Choice B is incorrect as assessing the client's body for bruising is not directly related to managing neglect syndrome. Choice C is incorrect as observing the interaction between the client and family members does not address the specific intervention needed for neglect syndrome. Choice D is incorrect because protecting the client's left side when transferring to a chair does not actively involve retraining the brain and improving awareness of the neglected side, which is the primary goal in managing neglect syndrome.

5. A client post-coronary artery bypass graft (CABG) surgery is concerned about the risk of infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?

• A. Avoid touching the incision sites with bare hands.
• B. Take all prescribed antibiotics as directed.
• C. Report any signs of infection to the healthcare provider immediately.
• D. Keep the incision sites clean and dry.

Correct answer: D

Rationale: The correct answer is D: 'Keep the incision sites clean and dry.' After CABG surgery, maintaining the cleanliness and dryness of the incision sites is crucial to prevent infections. This practice reduces the risk of introducing harmful microorganisms to the surgical wound, promoting healing and preventing complications. Option A, while important, does not fully encompass the preventive measures necessary to avoid infections post-surgery. Option B is significant if antibiotics are prescribed, but ensuring cleanliness directly addresses infection prevention. Option C is reactive and focuses on addressing infection after it occurs, rather than proactively preventing it.

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