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. When assessing for criteria that signify malnutrition risk, which element would most likely be included as part of the functional assessment data?

• A. severity of illness
• B. presence of pressure sores
• C. localized edema
• D. generalized weakness

Correct answer: D

Rationale: Generalized weakness is a key indicator of malnutrition and is often assessed as part of functional status, reflecting muscle wasting and reduced physical function. The other choices, such as severity of illness, presence of pressure sores, and localized edema, are important factors to consider in a clinical assessment but are not primarily indicative of malnutrition risk. Generalized weakness directly relates to the functional impact of malnutrition on physical performance.

3. The most important quality of a nurse during a Nurse-Patient interaction is:

• A. Understanding
• B. Acceptance
• C. Listening
• D. Teaching

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.

4. Mang Carlos has a standing DNR order. He then suddenly stopped breathing and you are at his bedside. You would:

• A. Give extraordinary measures to save Mang Carlos
• B. Stay with Mang Carlos and Do nothing
• C. Call the physician
• D. Activate Code Blue

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.

5. A patient with renal insufficiency should limit the intake of which of the following nutrients?

• A. Phosphorus
• B. Potassium
• C. Sodium
• D. Calcium

Correct answer: A

Rationale: In patients with renal insufficiency, impaired kidney function can lead to difficulty in excreting phosphorus. High phosphorus levels can result in further complications such as bone and heart problems. Therefore, limiting the intake of phosphorus is crucial. Potassium and sodium restrictions may also be necessary in renal insufficiency, but the primary concern related to nutrients is phosphorus in this scenario. Calcium, while important for bone health, does not typically need to be restricted in renal insufficiency unless there is a specific medical reason to do so.

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