Nursing Elites

1. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:

• A. perfusion
• B. locomotion
• C. respiration
• D. mentation

Correct answer: D

Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.

2. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if pt:

• A. Lubricates the tip of the catheter prior to inserting into the stoma
• B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
• C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
• D. Clamps of the flow of fluid when felling uncomfortable

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

3. What effect does the use of a hot compress have, as explained to Ronnie who has been prescribed pain medication?

• A. It produces an anesthetic effect
• B. It increases nutrition in the blood to promote wound healing
• C. It increases oxygenation to the injured tissues for better healing
• D. It induces vasoconstriction to prevent infection

Correct answer: A

Rationale: The correct answer is A: 'It produces an anesthetic effect.' Hot compresses can help alleviate pain by producing an anesthetic effect, which numbs the area. Choice B is incorrect because a hot compress does not directly increase nutrition in the blood to promote wound healing. Choice C is also incorrect because a hot compress primarily aids in pain relief rather than increasing oxygenation to the tissues for enhanced healing. Choice D is incorrect because hot compresses typically lead to vasodilation, not vasoconstriction, which aids in promoting blood flow rather than preventing infection. Safe and effective patient care relies on actions based on established nursing protocols that consider both the immediate and long-term needs of the patient.

4. A nurse is reinforcing teaching about food choices with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching?

• A. I will give my child strained carrots and mashed egg yolks.
• B. I will give my child rice cereal and crackers.
• C. I will give my child pureed liver and strained pears.
• D. I will give my child applesauce and green peas.

Correct answer: B

Rationale: Choice B, 'I will give my child rice cereal and crackers,' indicates a need for further teaching. Infants should not be given crackers at 8 months of age due to the risk of choking. Rice cereal is appropriate for infants, but it should be introduced carefully to avoid digestive issues. Choices A, C, and D are appropriate food choices for an 8-month-old infant, providing a variety of nutrients and textures suitable for their age and developmental stage.

5. What gastrointestinal side effects are associated with antisecretory drugs such as proton pump inhibitors?

• A. Nausea and vomiting
• B. Gastroparesis
• C. Dumping syndrome
• D. Flatulence

Correct answer: A

Rationale: Proton pump inhibitors (PPIs) are a type of antisecretory drug that can cause nausea and vomiting by altering stomach acid production. These are common side effects associated with PPIs. Gastroparesis (B) is a condition that affects the stomach muscles and prevents proper stomach emptying; it is not a side effect of PPIs. Dumping syndrome (C) is a group of symptoms that can occur after having part of your stomach removed and is not a side effect of PPIs. While some people might experience flatulence (D) when taking PPIs, it is not as commonly associated with these drugs as the effects of nausea and vomiting.

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