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. To prevent injury and strain on the muscles, the nurse should observe proper body mechanics. Among the following, which is a principle of proper body mechanics?

• A. Broaden the space between the feet
• B. Push instead of pull
• C. Move the object away from the body when lifting
• D. Bend at the waist, not on the knees

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

3. During the Emergent phase of a burn, the most fatal electrolyte imbalance in a burned client is:

• A. Hypokalemia
• B. Hyperkalemia
• C. Hypernatremia
• D. Hyponatremia

Correct answer: A

Rationale: During the Emergent phase of burns, the most fatal electrolyte imbalance is Hypokalemia. This is due to the shift of potassium from the intracellular space to the extracellular space, leading to low potassium levels in the blood. Choices B, C, and D are incorrect because Hyperkalemia, Hypernatremia, and Hyponatremia are not typically associated with the Emergent phase of burns and do not pose the same level of risk as Hypokalemia in this context.

4. What type of drug therapy is typically administered immediately after a heart attack?

• A. Antilipemic drugs
• B. Corticosteroids
• C. Diuretics
• D. Thrombolytic drugs

Correct answer: D

Rationale: Thrombolytic drugs are typically administered immediately after a heart attack to dissolve the clot blocking the coronary artery and restore blood flow to the heart muscle. Antilipemic drugs are used to lower lipid levels and prevent atherosclerosis, but they are not typically administered immediately after a heart attack. Corticosteroids are used to reduce inflammation and suppress the immune response, which are not immediate concerns after a heart attack. Diuretics are used to reduce fluid build-up and lower blood pressure, but these are not the primary concerns immediately following a heart attack.

5. The preferred route of administration of medication in the most acute care situations is which of the following routes?

• A. Intravenous C. Subcutaneous
• B. Epidural D. Intramuscular
• 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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