Nursing Elites

1. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

• A. Pink, moist, and slightly protruding from the abdomen
• B. Gray, moist, and slightly protruding from the abdomen
• C. Pink, dry, and slightly protruding from the abdomen
• D. Red, moist, and slightly protruding from the abdomen

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

2. A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing?

• A. One cup of brown rice
• B. One cup of orange juice
• C. One cup of pureed avocado
• D. One cup of lentils

Correct answer: D

Rationale: Lentils are an excellent source of plant-based protein, essential for wound healing in a vegan diet. Brown rice, orange juice, and pureed avocado are not protein-rich foods like lentils and would not provide sufficient protein for wound healing in this scenario.

3. Which nutrient is most important for the prevention of osteoporosis?

• A. Vitamin A
• B. Iron
• C. Calcium
• D. Protein

Correct answer: C

Rationale: Calcium is the most important nutrient for bone health and the prevention of osteoporosis. Calcium plays a crucial role in maintaining bone density and strength. Vitamin A is important for vision and immune function but is not directly related to bone health. Iron is essential for oxygen transport in the blood, while protein is important for muscle growth and repair. However, in the context of preventing osteoporosis, calcium is the key nutrient.

4. You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:

• A. Take the blood pressure reading on both arms for comparison
• B. Listen to and identify the phases of Korotkoff sounds
• C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
• D. Observe procedures for infection control

Correct answer: B

Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.

5. In alcoholic patient, the nurse knows that the vitamin deficient to these types of clients that leads to psychoses is:

• A. Thiamine C. Niacin
• B. Vitamin C D. Vitamin A
• C.
• D.

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

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