Nursing Elites

1. After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?

• A. Elevate the buttocks.
• B. Document the findings.
• C. Apply ice immediately.
• D. Call the primary health care provider.

Correct answer: B

Rationale: A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown. Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.

2. A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings?

• A. The patient states he had a manic episode a week ago
• B. The patient states he has been having diarrhea every day
• C. The patient presents as severely depressed
• D. The patient has a rash and pruritus on his arms and legs

Correct answer: B

Rationale: The correct answer is when the patient states he has been having diarrhea every day. Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity. The other options, such as a manic episode, severe depression, or rash and pruritus, are not directly associated with an increased risk of lithium toxicity.

3. The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

• A. Increased tactile fremitus
• B. Dry, nonproductive cough
• C. Hyperresonance to percussion
• D. A grating sound on auscultation

Correct answer: A

Rationale: Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias, such as pneumococcal pneumonia. Dullness to percussion would be expected due to consolidation. Pneumococcal pneumonia typically presents with a loose, productive cough rather than a dry, nonproductive cough. Hyperresonance to percussion is not a typical finding in pneumonia and may suggest conditions like emphysema. Adventitious breath sounds such as crackles and wheezes are typical in pneumonia, but a grating sound on auscultation is more representative of a pleural friction rub rather than pneumonia.

4. Which of the following clients is most appropriate for receiving telemetry?

• A. A client with syncope potentially related to cardiac dysrhythmia
• B. A client with unstable angina
• C. A client with sinus rhythm and PVCs
• D. A client who had a myocardial infarction 6 hours ago

Correct answer: A

Rationale: Telemetry is used to monitor the cardiac rhythms of clients with potentially unstable conditions or those rhythms that affect activities. Clients with syncope potentially related to cardiac dysrhythmia require continuous monitoring to detect any potential life-threatening dysrhythmias. Unstable angina can be monitored in a telemetry unit, but syncope with potential cardiac causes takes precedence. Clients with sinus rhythm and PVCs may not necessitate telemetry unless there are further indications of instability. A client who had a myocardial infarction 6 hours ago is typically monitored in an intensive care unit rather than a telemetry unit.

5. Which of the following types of dressing changes works as a form of wound debridement?

• A. Dry dressing
• B. Transparent dressing
• C. Composite dressing
• D. Wet to dry dressing

Correct answer: D

Rationale: The correct answer is 'Wet to dry dressing.' Wet to dry dressing is a method of wound debridement that involves applying sterile soaked gauze to the wound, allowing it to dry and stick to the wound. When the dressing is removed, it pulls away drainage and debris, aiding in wound debridement. Choice A, 'Dry dressing,' does not actively assist in debridement as it does not collect or remove debris from the wound. Choice B, 'Transparent dressing,' is primarily used for maintaining a moist environment and wound observation, not for debridement. Choice C, 'Composite dressing,' combines multiple layers for different wound care purposes but is not specifically designed for debridement like wet to dry dressing.

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