Nursing Elites

1. What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?

• A. Cleanse the stoma with hydrogen peroxide and water.
• B. Apply a moisture barrier cream to the peristomal skin.
• C. Measure the stoma using a stoma guide.
• D. Use a dry gauze pad to clean the stoma.

Correct answer: C

Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.

2. The client is being instructed on the proper use of a metered-dose inhaler. Which instruction should be provided to ensure the optimal benefits from the drug?

• A. Fill your lungs with air through your mouth and then compress the inhaler.
• B. Compress the inhaler while slowly breathing in through your mouth.
• C. Compress the inhaler while inhaling quickly through your nose.
• D. Exhale completely after compressing the inhaler and then inhale.

Correct answer: B

Rationale: The correct technique for using a metered-dose inhaler involves compressing the inhaler while slowly breathing in through the mouth. This method helps ensure that the medication reaches deep into the lungs, allowing for optimal bronchodilation effect. Inhaling quickly through the nose or filling the lungs with air before compressing the inhaler are not recommended techniques for using a metered-dose inhaler effectively.

3. An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first?

• A. Apply flannel pajamas to provide warmth.
• B. Administer a PRN dose of ibuprofen.
• C. Perform range of motion exercises in a warm tub.
• D. Drape the sheets over the footboard of the bed.

Correct answer: D

Rationale: The correct answer is D. The nurse should first address the immediate comfort concern of the client, which is the weight of the linen on her legs causing severe joint pain. By draping the sheets over the footboard of the bed rather than tucking them under the mattress, the nurse can alleviate the pressure that the client perceives as the source of her pain. This action is a simple and effective way to provide relief and should be the initial step taken by the nurse. Choices A, B, and C do not directly address the client's immediate discomfort caused by the weight of the linen on her legs, making them less appropriate initial actions.

4. A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?

• A. Gallbladder disease
• B. Liver disease
• C. Myocardial infarction
• D. Skeletal muscle injury

Correct answer: C

Rationale: An elevated AST level following chest pain and shortness of breath is suggestive of myocardial infarction. AST is released from damaged heart muscle cells during a heart attack, indicating cardiac involvement. This enzyme is not specific to liver disease, gallbladder disease, or skeletal muscle injury in this clinical context.

5. During the assessment, a client receiving a continuous infusion of heparin for deep vein thrombosis (DVT) is found to have a nosebleed. Which finding requires immediate action?

• A. The client's activated partial thromboplastin time (aPTT) is 70 seconds.
• B. The client has developed a nosebleed.
• C. The client's blood pressure is 150/90 mm Hg.
• D. The client reports feeling lightheaded.

Correct answer: B

Rationale: A nosebleed (B) in a client receiving heparin is a sign of heparin toxicity and requires immediate action. It indicates that the client is at risk of excessive bleeding. While a prolonged aPTT of 70 seconds (A) is worth monitoring, active bleeding takes precedence. Elevated blood pressure (C) and lightheadedness (D) are potential side effects of heparin but are not as urgently concerning as active bleeding.

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