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. The nurse is working with a patient who recently had a stroke. The patient frequently chokes and coughs when eating and is having difficulty feeding herself. What is the best way to ensure adequate nutrition?

• A. to have an aide feed her at each meal
• B. to ask a family member to assist during meals
• C. to provide tube feedings for the patient
• D. to initiate TPN for the patient

Correct answer: C

Rationale: The best way to ensure adequate nutrition for a stroke patient who frequently chokes and coughs when eating and has difficulty feeding herself is to provide tube feedings. Tube feedings are a safe and effective method to deliver nutrition directly to the stomach or intestines, bypassing the swallowing mechanism, reducing the risk of aspiration. Having an aide feed her each meal (choice A) may not address the underlying issue of swallowing difficulty and aspiration risk. Asking a family member to be present at each meal (choice B) does not provide a definitive solution to the patient's nutritional needs. Placing the patient on total parenteral nutrition (TPN) (choice D) is a more invasive and typically reserved for patients who cannot tolerate enteral feedings or have non-functional gastrointestinal tracts.

3. What does oliguria lead to in patients with acute kidney injury?

• A. Hypophosphatemia and overgrowth of bone tissue
• B. An increase in blood potassium levels due to excessive excretion of parathyroid hormone
• C. Sodium retention and elevated levels of potassium
• D. Edema due to increased urine production

Correct answer: C

Rationale: In patients with acute kidney injury, oliguria (reduced urine output) often results in sodium retention and hyperkalemia (elevated levels of potassium). This is due to the kidneys' decreased capacity to excrete these substances. Choice A is incorrect because hypophosphatemia and overgrowth of bone tissue are not direct consequences of oliguria in acute kidney injury. Choice B is incorrect because an increase in blood potassium levels is not caused by excessive excretion of parathyroid hormone but rather by decreased excretion of potassium. Choice D is incorrect because edema is not caused by increased urine production but rather by fluid overload due to decreased urine output.

4. Which statement about essential nutrients should the nurse include?

• A. Fat-containing foods can help to decrease triglyceride levels.
• B. Animal sources of protein contain 20 essential amino acids.
• C. Carbohydrates are the primary source of fuel for muscles and the brain.
• D. High-fiber foods are a good source of energy.

Correct answer: C

Rationale: The correct answer is C because carbohydrates are indeed the primary source of fuel for muscles and the brain. Choice A is incorrect because while certain fats are essential, they do not help decrease triglyceride levels. Choice B is incorrect because animal sources of protein do not contain all 20 essential amino acids. Choice D is incorrect because although high-fiber foods are important for digestion and overall health, they are not a direct source of energy.

5. In approximately what percentage of cases is the prevalence seen?

• A. Type 1 Diabetes
• B. Type 2 Diabetes
• C. N/A
• D. N/A

Correct answer: A

Rationale: The correct answer is A, Type 1 Diabetes. The prevalence of Type 1 Diabetes is seen in approximately 5% to 10% of cases. This statement highlights a key epidemiological characteristic of Type 1 Diabetes. Choice B, Type 2 Diabetes, is incorrect because the prevalence mentioned does not align with Type 2 Diabetes, which has a much higher prevalence in the general population. Choices C and D are not relevant to the question and can be disregarded.

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