Nursing Elites

1. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer:

• A. To the exact size of the stoma.
• B. About 1/16” larger than the stoma.
• C. About 1/8” larger than the stoma.
• D. About 1/4″ larger than the stoma.

Correct answer: C

Rationale: The wafer should be measured and cut about 1/8” larger than the stoma to ensure proper fit and prevent skin irritation.

2. Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?

• A. Administering pain medication.
• B. Completing the admission history.
• C. Maintaining hydration.
• D. Teaching about planned diagnostic tests.

Correct answer: A

Rationale: Administering pain medication would have the highest priority during the first hour after the client's admission. Pain relief is essential to address the client's immediate discomfort and distress. Completing the admission history, maintaining hydration, and teaching about planned diagnostic tests are important aspects of care but can be addressed after addressing the client's pain and stabilizing their condition.

3. Which of the following symptoms is associated with ulcerative colitis?

• A. Dumping syndrome
• B. Rectal bleeding
• C. Soft stools
• D. Fistulas

Correct answer: B

Rationale: Rectal bleeding is a common symptom of ulcerative colitis due to the inflammation and ulceration of the colon lining.

4. You’re caring for a 28 y.o. woman with hepatitis B. She’s concerned about the duration of her recovery. Which response isn’t appropriate?

• A. Encourage her to not worry about the future.
• B. Encourage her to express her feelings about the illness.
• C. Discuss the effects of hepatitis B on future health problems.
• D. Provide avenues for financial counseling if she expresses the need.

Correct answer: A

Rationale: Encouraging the patient to not worry about the future is not appropriate. Instead, address her concerns and provide information.

5. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?

• A. Assessing the client's bowel sounds
• B. administration of pain medication every 4 hours
• C. Evaluating the client's response to antidiarrheal medications
• D. Maintaining intake and output records

Correct answer: D

Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.

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