Nursing Elites

1. A client with a colostomy needs optimal skin integrity. What action should the nurse take to promote this?

• A. Cleanse the peristomal skin with alcohol.
• B. Change the colostomy pouch every 3 days.
• C. Use a barrier cream to protect the skin from the pouch contents.
• D. Cleanse the stoma with hydrogen peroxide.

Correct answer: C

Rationale: To promote optimal skin integrity in a client with a colostomy, using a barrier cream to protect the skin from the irritating effects of the colostomy pouch contents is essential. Cleansing the peristomal skin with alcohol (Choice A) can be too harsh and drying for the skin. Changing the colostomy pouch every 3 days (Choice B) is important for hygiene but using a barrier cream is more directly related to skin protection. Cleaning the stoma with hydrogen peroxide (Choice D) is not recommended as it can be too abrasive for the sensitive stoma area.

2. A healthcare provider is assessing a client who has heart failure and is taking digoxin. Which of the following findings should the healthcare provider identify as an indication of digoxin toxicity?

• A. Bradycardia.
• B. Yellow-tinged vision.
• C. Constipation.
• D. Hypertension.

Correct answer: B

Rationale: Yellow-tinged vision is a classic sign of digoxin toxicity due to its effect on the eyes. It can cause a yellow or green visual halo around objects. Bradycardia, constipation, and hypertension are not typical signs of digoxin toxicity. Bradycardia may be a sign of digoxin's therapeutic effect in heart failure, while constipation and hypertension are not commonly associated with digoxin toxicity.

3. A nurse is providing discharge teaching to a client who has a new prescription for lithium. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. Avoid eating foods that contain tyramine.
• C. Drink at least 2 liters of water each day.
• D. Take this medication in the evening before bedtime.

Correct answer: C

Rationale: The correct instruction for a client prescribed lithium is to drink at least 2 liters of water each day. This is important to prevent dehydration and reduce the risk of lithium toxicity. Option A is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Option B is unrelated to lithium and is more applicable to clients taking MAOIs. Option D is incorrect as lithium is typically taken in divided doses throughout the day to maintain therapeutic levels.

4. A client with diabetes mellitus is being taught by a nurse about managing blood glucose levels. Which of the following client statements indicates an understanding of the teaching?

• A. I will eat a snack if my blood glucose level is below 70 mg/dL.
• B. I will take my insulin if my blood glucose level is above 200 mg/dL.
• C. I will check my blood glucose level once a week.
• D. I will take my insulin only when I feel symptoms of hyperglycemia.

Correct answer: A

Rationale: Choice A is the correct answer because consuming a snack when the blood glucose level is below 70 mg/dL helps prevent hypoglycemia in clients with diabetes mellitus. Choice B is incorrect because taking insulin when blood glucose is high (above 200 mg/dL) helps manage hyperglycemia, not hypoglycemia. Choice C is incorrect as checking blood glucose levels once a week is insufficient for proper diabetes management, which typically requires more frequent monitoring. Choice D is incorrect because waiting for symptoms of hyperglycemia to take insulin can lead to uncontrolled blood glucose levels.

5. A nurse is reviewing the medical record of a client who is receiving heparin to treat deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?

• A. aPTT of 38 seconds
• B. Hemoglobin of 15 g/dL
• C. Platelet count of 80,000/mm3
• D. INR of 1.0

Correct answer: C

Rationale: A platelet count of 80,000/mm3 is below the normal range and should be reported to the provider due to the risk of bleeding. Heparin can cause a rare but serious side effect known as heparin-induced thrombocytopenia, leading to a decrease in platelet count and an increased risk of bleeding. The aPTT of 38 seconds, hemoglobin of 15 g/dL, and an INR of 1.0 are within normal ranges and not directly concerning in this scenario. Platelet count is crucial to monitor in clients receiving heparin therapy to ensure adequate clotting function and prevent bleeding complications.

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