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. People who use monoamine oxidase inhibitors for the treatment of depression need to avoid foods high in:

• A. Folate
• B. Tyramine
• C. Potassium
• D. Vitamin K

Correct answer: B

Rationale: The correct answer is B: Tyramine. When individuals taking monoamine oxidase inhibitors (MAOIs) consume foods high in tyramine, it can lead to a potentially dangerous increase in blood pressure known as a hypertensive crisis. Foods high in tyramine include aged cheeses, cured meats, and certain fermented foods. Choices A, C, and D are incorrect. Folate, potassium, and vitamin K are not typically contraindicated with the use of MAOIs.

3. Infection or inflammation of small sacs that protrude from the lumen of the colon is known as:

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

Correct answer: B

Rationale: Diverticulitis refers to the infection or inflammation of diverticula in the colon. Choice A, Diverticulosis, is the condition of having diverticula without inflammation. Choices C and D, Cholelithiasis and Cholecystitis, are related to the gallbladder and not the colon, making them incorrect in this context.

4. Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison’s disease?

• A. Discuss the importance of tapering medications when discontinuing medication
• B. Explain that the dose will need to be decreased during times of stress or infection
• C. Instruct the client to take medication on an empty stomach with a glass of water
• D. Encourage the client to wear a MedicAlert bracelet and carry a card in the wallet

Correct answer: A

Rationale: The correct answer is to discuss the importance of tapering medications when discontinuing medication. Tapering glucocorticoids is crucial to prevent adrenal insufficiency, which can occur if the medication is stopped abruptly. Choice B is incorrect because it focuses on adjustments during stress or infection, not discontinuation. Choice C is unrelated to the management of glucocorticoids. Choice D is important for emergency identification but is not directly related to medication management.

5. Performing and supervising therapeutic and preventive procedures that have been planned for a patient is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: C

Rationale: The correct answer is C: Implementation. Implementation in nursing care involves the actual performance and supervision of the planned therapeutic and preventive procedures for a patient. Evaluation (choice A) is the step where the effectiveness of the interventions is assessed. Planning (choice B) is the phase where the nursing care plan is developed based on the assessment. Assessment (choice D) is the initial step in the nursing process, involving data collection and analysis to determine the patient's needs.

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