Nursing Elites

1. Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?

• A. Taking a health history and performing a physical exam prior to the procedure
• B. Instructing the client about how to care for his colostomy stoma
• C. Developing goals that state the client will ambulate three times a day
• D. Determining that the client may need more support at home after dismissal

Correct answer: B

Rationale: The intervention stage of the individualized nursing care plan is where the nurse provides care, treatments, or education to help the client meet the devised outcomes. Instructing the client about how to care for his colostomy stoma is the correct example of an intervention as it directly involves providing education and guidance to the client on post-operative care. This intervention supports the process of helping the client meet the outcomes designed for this case, which is to enable the client to properly care for his colostomy after a bowel resection. The other options do not directly involve interventions aimed at assisting the client in meeting the specific care needs related to the colostomy procedure.

2. A nursing unit is implementing a new electronic charting program for the nursing staff to use. Which of the following best describes a disadvantage of using electronic charting?

• A. The information is more likely to be lost or used inappropriately.
• B. Any provider in the unit can have access to the client's medical records.
• C. The system diminishes communication between nurses and providers.
• D. The program may be confusing and difficult to implement.

Correct answer: D

Rationale: A significant disadvantage of implementing a new electronic charting program is the potential for complexity and difficulty in implementation. Introducing a new system requires time and education for staff to adapt and use it appropriately. Users may experience confusion as they learn to navigate the new charting techniques, which can impact workflow efficiency and accuracy. Option A is incorrect because electronic charting systems are designed to enhance data security and integrity, reducing the risk of information being lost or misused. Option B is incorrect as access control mechanisms can restrict who can view specific patient records. Option C is incorrect as electronic charting systems often facilitate communication between healthcare providers by providing real-time access to patient information.

3. A new mother has some questions about phenylketonuria (PKU). Which of the following statements made by a nurse is not correct regarding PKU?

• A. A Guthrie test can check the necessary lab values.
• B. The urine has a high concentration of phenylpyruvic acid
• C. Mental deficits are often present with PKU
• D. The effects of PKU are reversible

Correct answer: D

Rationale: Phenylketonuria (PKU) is an inherited disorder that increases the levels of phenylalanine (a building block of proteins) in the blood. If PKU is not treated, phenylalanine can build up to harmful levels in the body, causing intellectual disability and other serious health problems. The signs and symptoms of PKU vary from mild to severe. The most severe form of this disorder is known as classic PKU. Infants with classic PKU appear normal until they are a few months old. Without treatment, these children develop a permanent intellectual disability. Seizures, delayed development, behavioral problems, and psychiatric disorders are also common. Untreated individuals may have a musty or mouse-like odor as a side effect of excess phenylalanine in the body. Children with classic PKU tend to have lighter skin and hair than unaffected family members and are also likely to have skin disorders such as eczema. The effects of PKU stay with the infant throughout their life (via Genetic Home Reference).

4. You are caring for a Hispanic patient who is scheduled for surgery in the morning. A member of the surgery staff is in a hurry when she visits the patient to obtain surgical consent. You know that the patient speaks limited English and can see that he does not really understand what's being said. What is the most appropriate next action?

• A. Call a family member to interpret
• B. Consult the hospital translator to assist
• C. Allow the consent to be signed
• D. Ask the staff member to come back later

Correct answer: B

Rationale: Consulting the hospital translator is the most reliable means of ensuring accuracy in the information that the patient is receiving. Family members can be helpful, but they may have difficulty understanding the medical procedures well enough to explain them accurately and may misinterpret the message. Relying on family members could lead to misunderstandings or miscommunication. Allowing the consent to be signed without ensuring the patient's full understanding could pose risks to the patient's well-being. Asking the staff member to come back later delays the essential communication process needed before surgery. Therefore, consulting the hospital translator is the best course of action to ensure clear and accurate communication, especially in critical healthcare decisions like surgical consent.

5. What information should be collected when assessing the health status of a community?

• A. Air pollution levels
• B. Number of health food stores
• C. Most common causes of death
• D. Education level of the individuals

Correct answer: C

Rationale: When assessing the health status of a community, it is crucial to gather data on various health measures such as the most common causes of death. This information helps in understanding the prevalent health issues within the community. Factors like air pollution levels, the number of health food stores, and the education level of individuals are important community aspects but do not directly reflect the health status of the community. Therefore, the correct answer is to collect data on the most common causes of death as it provides insights into the major health concerns affecting the community.

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