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 is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?

• A. Encourage the client to drink liquids
• B. Perform active range of motion exercises
• C. Elevate the head of the bed to 45 degrees
• D. Provide a high-fiber diet to the client

Correct answer: B

Rationale: The correct answer is to perform active range of motion exercises. When a client is on strict bed rest, performing range of motion exercises is a priority to prevent complications such as thromboembolism and muscle atrophy. Option A may be important but not the priority compared to maintaining mobility. Option C is incorrect because elevating the head of the bed to 45 degrees is not necessary for a client on strict bed rest. Option D, providing a high-fiber diet, is also not the priority intervention compared to ensuring range of motion exercises are performed.

3. Which of the following is the primary enlisted personnel performing nursing care duties at the various levels of health care?

• A. 68A30
• B. 68WM6
• C. Physician assistant
• D. 6.80E+21

Correct answer: B

Rationale: The correct answer is B: 68WM6. The 68WM6 (Practical Nurse) is the primary enlisted personnel performing nursing care duties. Choice A (68A30) does not correspond to a primary enlisted personnel role in nursing. Choice C (Physician assistant) is not an enlisted personnel role but rather a separate healthcare profession. Choice D (6.80E+21) is a numerical value and does not relate to enlisted personnel performing nursing care duties.

4. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

• A. The assistant is putting the stockings on while the client is in the chair
• B. The assistant inserted two (2) fingers under the proximal end of the stocking
• C. The assistant elevated the feet while lying down to put on the stockings
• D. The assistant made sure the toes were warm after putting the stockings on

Correct answer: A

Rationale: The correct answer is A. Compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is incorrect as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C is incorrect as elevating the feet while lying down is a correct technique for applying compression stockings. Choice D is incorrect as ensuring the toes are warm after putting the stockings on is a good practice for client comfort.

5. A client is ordered lisinopril (Zestril) for the treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should inform him about which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors?

• A. Constipation
• B. Dizziness
• C. Headache
• D. B, C

Correct answer: D

Rationale: The correct answer is D: 'B, C.' Dizziness and headache are common side effects of ACE inhibitors due to their blood pressure-lowering effects. Constipation is not a common adverse effect associated with ACE inhibitors, so choice A is incorrect. Choice B (Dizziness) and choice C (Headache) are more commonly seen and are directly related to the mechanism of action of ACE inhibitors, making them the correct choices.

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