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. The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, 'Why did this happen to my child? I just can't cope with this.' How should the PN respond?

• A. Ask her to share how the injury occurred to her child.
• B. Recommend that she remain calm and positive for her child.
• C. Express that the present situation must be overwhelming.
• D. Determine if someone else can help her cope with this tragedy.

Correct answer: C

Rationale: Expressing empathy and acknowledging the mother's feelings helps in providing emotional support during a difficult time. This response validates her emotions and offers a comforting presence. Choice A is not appropriate as it focuses on gathering information rather than addressing the mother's emotional distress. Choice B may come off as dismissive of the mother's feelings and oversimplifies the complexity of the situation. Choice D shifts the responsibility to someone else instead of offering immediate support and comfort.

3. An older postoperative client has the nursing diagnosis 'impaired mobility related to fear of falling.' Which desired outcome best directs the PN'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 PN will place a gait belt on the client prior to ambulation

Correct answer: C

Rationale: The correct answer is C. Using self-affirmation statements helps the client reduce fear and regain confidence in mobility, which is essential for improving impaired mobility. Choice A focuses more on the frequency of ambulation rather than addressing the fear of falling. Choice B involves the physical therapist and the use of a walker, which may not directly address the client's fear. Choice D is a safety measure but does not specifically target the client's fear of falling.

4. The nurse and UAP enter a client's room and find the client lying on the bed. The nurse determines that the client is unresponsive. Which instruction should the nurse give the UAP first?

• A. Obtain emergency help
• B. Feel for a carotid pulse
• C. Bring a glucometer to the room
• D. Check the blood pressure

Correct answer: A

Rationale: The correct answer is to instruct the UAP to obtain emergency help first. In a situation where a client is unresponsive, the priority is to ensure that help is summoned promptly. This allows for the availability of necessary resources and assistance for resuscitation or other emergency interventions. Feeling for a carotid pulse or checking the blood pressure can be important assessments but are secondary to obtaining immediate help. Bringing a glucometer to the room, while relevant in certain situations, is not the priority when the client's unresponsiveness indicates a need for urgent intervention.

5. A post-operative client is prescribed sequential compression devices (SCDs) while on bed rest. What is the primary purpose of this device?

• A. To prevent deep vein thrombosis (DVT).
• B. To improve circulation in the legs.
• C. To prevent pressure ulcers.
• D. To alleviate post-operative pain.

Correct answer: A

Rationale: The correct answer is A: 'To prevent deep vein thrombosis (DVT).' Sequential compression devices (SCDs) are primarily used to prevent deep vein thrombosis (DVT) by promoting blood flow in the legs and reducing venous stasis, which is a common risk for post-operative clients who are on bed rest. While SCDs do improve circulation in the legs indirectly, their primary purpose is DVT prevention. Preventing pressure ulcers is typically achieved through repositioning and support surfaces, not with SCDs, making choice C incorrect. SCDs are not used to alleviate post-operative pain, so choice D is also incorrect.

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