Nursing Elites

1. A client is scheduled for a sigmoidoscopy and expresses anxiety about the procedure. What should the nurse do first?

• A. Offer information about the procedure steps
• B. Administer an anxiolytic before the procedure
• C. Encourage the client to discuss their fears
• D. Reassure the client that the procedure is common and safe

Correct answer: C

Rationale: The correct first action for the nurse when a client expresses anxiety about a procedure is to encourage the client to discuss their fears. By allowing the client to express their concerns, the nurse can provide personalized support, address specific worries, and offer tailored information. This approach helps to establish trust, reduce anxiety, and promote a therapeutic nurse-client relationship. Offering information about the procedure steps (Choice A) may be helpful but should come after addressing the client's fears. Administering an anxiolytic (Choice B) should not be the first action as it focuses on symptom management rather than addressing the underlying cause of anxiety. Reassuring the client that the procedure is common and safe (Choice D) is important but should follow active listening and addressing the client's fears.

2. What is the most important aspect of colostomy care to teach the client?

• A. Change the colostomy bag only when necessary
• B. Eat a low-residue diet
• C. Assess the stoma for color and swelling
• D. Irrigate the colostomy only if advised by a healthcare provider

Correct answer: C

Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.

3. During a health screening, a client's blood pressure reads 160/100 mm Hg. What should the nurse recommend?

• A. Schedule a follow-up appointment
• B. Start making immediate dietary changes
• C. Begin an exercise program
• D. All of the above

Correct answer: A

Rationale: A follow-up with a healthcare provider is necessary to assess and manage the newly identified hypertension. While dietary changes and exercise are important for managing high blood pressure, immediate lifestyle modifications without further evaluation by a healthcare provider may not be safe or effective. Option A is the most appropriate initial step to ensure proper assessment and management of the client's blood pressure. Therefore, choices B and C are incorrect in this scenario. Option D is also incorrect because not all options should be implemented without proper medical guidance.

4. A client with a diagnosis of chronic kidney disease (CKD) is receiving epoetin alfa (Epogen). What is the primary goal of this medication?

• A. To reduce the risk of bleeding.
• B. To lower blood pressure.
• C. To stimulate red blood cell production.
• D. To increase appetite.

Correct answer: C

Rationale: The correct answer is C: 'To stimulate red blood cell production.' Epoetin alfa, such as Epogen, is used to treat anemia by stimulating red blood cell production in clients with chronic kidney disease. This medication helps increase hemoglobin levels and reduce the need for blood transfusions. Option A, 'To reduce the risk of bleeding,' is incorrect as epoetin alfa does not directly impact bleeding risk. Option B, 'To lower blood pressure,' is incorrect as epoetin alfa is not indicated for blood pressure management. Option D, 'To increase appetite,' is also incorrect as the primary goal of epoetin alfa is related to improving anemia by boosting red blood cell production.

5. The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?

• A. Encourage the client to ambulate
• B. Apply a heating pad
• C. Provide a carbonated beverage
• D. Teach relaxation techniques

Correct answer: A

Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.

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