Nursing Elites

1. Which intervention should the nurse implement for the client who has an ileal conduit?

• A. Pouch the stoma with a one-inch margin around the stoma
• B. Refer the client to the United Ostomy Association for discharge teaching
• C. Report to the healthcare provider any decrease in urinary output
• D. Monitor the stoma for signs and symptoms of infection every shift

Correct answer: C

Rationale: The correct intervention for a client with an ileal conduit is to report to the healthcare provider any decrease in urinary output. A decrease in urinary output can be indicative of a blockage or other complication, necessitating immediate attention. Choice A is incorrect because pouching the stoma with a margin around it is not directly related to managing complications. Choice B is incorrect as referring the client to an ostomy association may be beneficial for education but is not the immediate action needed for decreased urinary output. Choice D is incorrect because monitoring for infection, although important, is not the priority when dealing with a potential complication like decreased urinary output.

2. The nurse counsels a client diagnosed with iron deficiency anemia. The nurse determines that teaching is effective if the client selects which of the following menus?

• A. Roast beef, brown rice, green beans, carrot and raisin salad, and milk
• B. Cheese pizza, tossed green salad, oatmeal-raisin cookie, and lemonade
• C. Two scrambled eggs, bacon, white toast with strawberry jam, and coffee
• D. Corn flakes with milk, whole wheat toast, and orange juice

Correct answer: A

Rationale: The correct answer is A. Roast beef is high in heme iron, which is best absorbed and helps treat iron deficiency anemia. Choices B, C, and D do not contain significant sources of iron, especially heme iron, making them less effective in treating iron deficiency anemia.

3. What is the term for the infection of small sacs that protrude from the lumen of the colon?

• A. Diverticulosis
• B. Diverticulitis
• C. Cholelithiasis
• D. Cholecystitis

Correct answer: B

Rationale: The correct answer is B: Diverticulitis. Diverticulitis specifically refers to the infection or inflammation of diverticula in the colon. Choice A, Diverticulosis, is incorrect as it refers to the condition of having diverticula without inflammation or infection. Choices C and D, Cholelithiasis and Cholecystitis, are unrelated conditions affecting the gallbladder, not the colon.

4. What is a primary intervention for managing hyperphosphatemia?

• A. Increasing calcium intake
• B. Increasing phosphorus intake
• C. Decreasing calcium intake
• D. Administering phosphate binders

Correct answer: D

Rationale: Administering phosphate binders is a primary intervention for managing hyperphosphatemia. Phosphate binders work by binding phosphorus in the gut, preventing its absorption. Increasing calcium intake (Choice A) is not a primary intervention for hyperphosphatemia and can actually exacerbate the condition by potentially raising calcium levels. Increasing phosphorus intake (Choice B) is contraindicated in hyperphosphatemia. Decreasing calcium intake (Choice C) may help manage hypercalcemia but is not the primary intervention for hyperphosphatemia.

5. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

• A. Deep tendon reflexes
• B. Arterial blood gases
• C. Skin turgor
• D. Capillary refill time

Correct answer: A

Rationale: Corrected Rationale: When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Assessing arterial blood gases, skin turgor, or capillary refill time is not directly related to the administration of magnesium sulfate in this scenario.

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