Nursing Elites

1. A client is post-operative day one following a colostomy surgery. The nurse notices the stoma is dark purple. What is the most appropriate action?

• A. Document the finding and continue to monitor.
• B. Apply warm compresses to the stoma.
• C. Notify the healthcare provider immediately.
• D. Encourage the client to ambulate.

Correct answer: C

Rationale: A dark purple stoma may indicate compromised blood flow to the stoma, which is an emergency. Immediate notification of the healthcare provider is necessary to prevent further complications. Simply documenting and monitoring the finding (Choice A) could lead to delays in addressing a potentially serious issue. Applying warm compresses to the stoma (Choice B) may not address the underlying cause of the dark purple color. Encouraging the client to ambulate (Choice D) is not the priority when a compromised blood flow to the stoma is suspected.

2. The PN reviews a client's medication history and learns that the client takes an anticoagulant and has recently started taking phenytoin. Which instruction should the PN provide when assigning the client's morning care to a UAP?

• A. Measure the temperature every 4 hours
• B. Elevate both feet on two pillows
• C. Initiate hourly turning schedule
• D. Protect skin from injury and bruising

Correct answer: D

Rationale: The correct answer is D: Protect skin from injury and bruising. Phenytoin and anticoagulants both increase the risk of bleeding. Protecting the skin from injury and bruising is critical to prevent complications, making it important to instruct the UAP accordingly. Measuring the temperature every 4 hours (Choice A) may not be directly related to the client's medications. Elevating both feet on two pillows (Choice B) is more relevant for issues like edema. Initiating an hourly turning schedule (Choice C) is important for preventing pressure ulcers, but in this case, the priority is to prevent bleeding due to the medications.

3. The PN is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the PN document in the medical record?

• A. Altered thought processes
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of heard words, is associated with disturbed thought processes, which are commonly seen in schizophrenia. Altered thought processes (Choice A) is a generic term and does not specifically address the behavior of repeating words. Impaired social interaction (Choice B) is not the primary concern when a client repeats the last words heard. Risk for self-directed violence (Choice C) is not directly related to the behavior of repeating words but focuses on the potential harm the client may cause to themselves.

4. In which stage of Maslow's hierarchy of needs is a young adult attempting to achieve when deciding to change his work hours to devote more time to his community?

• A. Self-Actualization
• B. Intimacy vs. Isolation
• C. Altruism
• D. Purposefulness

Correct answer: A

Rationale: The correct answer is A: Self-Actualization. The young adult is striving for self-actualization, the highest level in Maslow's hierarchy of needs. Self-actualization is characterized by individuals seeking personal growth, self-fulfillment, and the ability to contribute to society. Choice B, Intimacy vs. Isolation, focuses on relationships and occurs at a different stage. Choice C, Altruism, although related to community contribution, does not specifically address personal growth and fulfillment as in self-actualization. Choice D, Purposefulness, is not a stage in Maslow's hierarchy of needs and is not directly relevant to the scenario described.

5. What is the primary reason for applying sequential compression devices (SCDs) to a patient’s legs postoperatively?

• A. To prevent deep vein thrombosis (DVT)
• B. To promote wound healing
• C. To reduce postoperative pain
• D. To maintain body temperature

Correct answer: A

Rationale: The correct answer is A: To prevent deep vein thrombosis (DVT). Sequential compression devices (SCDs) are used postoperatively to prevent DVT by promoting blood circulation in the legs. This helps reduce the risk of blood clots forming in the deep veins of the legs. Choice B, to promote wound healing, is incorrect as SCDs are primarily used for circulatory purposes rather than wound healing. Choice C, to reduce postoperative pain, is incorrect as the primary purpose of SCDs is not pain management but rather prevention of DVT. Choice D, to maintain body temperature, is incorrect as SCDs are not designed for regulating body temperature but for preventing circulatory issues.

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