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 client with a new diagnosis of hypertension is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will check my blood pressure at least once a week.
• B. I will avoid eating foods high in potassium.
• C. I should exercise for 30 minutes at least 5 days a week.
• D. I will take my medication only when I feel dizzy.

Correct answer: C

Rationale: The correct answer is C. Regular exercise is an essential component in managing hypertension. Exercising for at least 30 minutes a day, at least 5 days a week, can help control blood pressure. Checking blood pressure regularly (choice A) is important, but not as indicative of understanding the teaching as the commitment to regular exercise. Avoiding foods high in potassium (choice B) is not a typical recommendation for managing hypertension. Taking medication only when feeling dizzy (choice D) is incorrect and potentially dangerous; medications should be taken as prescribed by the healthcare provider.

3. A nurse is providing teaching to a client who is at 36 weeks of gestation and is scheduled for a nonstress test. Which of the following instructions should the nurse include?

• A. The test will last about 30 minutes.
• B. You should drink a full glass of water prior to the test.
• C. You will need to have your bladder full for this test.
• D. This test measures how well your baby's heart responds to movement.

Correct answer: D

Rationale: The correct answer is D. A nonstress test measures the fetal heart's response to movement, helping to assess fetal well-being. Choice A is incorrect as the duration of the test can vary, and it is not always precisely 30 minutes. Choice B is incorrect as drinking water is not necessary for a nonstress test. Choice C is incorrect as having a full bladder is not required for this test.

4. What is the priority nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Perform a neurological exam

Correct answer: A

Rationale: The correct answer is to administer oxygen. Post-surgery, confusion in a patient could be due to hypoxia, a condition where the body is deprived of an adequate oxygen supply. Administering oxygen helps address hypoxia promptly, improving oxygen levels in the body and potentially resolving the confusion. Repositioning the patient, checking oxygen saturation, and performing a neurological exam may be important interventions but addressing hypoxia with oxygen administration takes precedence as the priority action.

5. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian for which of the following clients?

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: B

Rationale: The correct answer is B. A client with gout who plans to continue consuming anchovies should be referred to a dietitian for proper dietary education. Anchovies are high in purines, which can exacerbate gout symptoms. Choices A, C, and D do not require immediate dietitian referral as the statements made by these clients are appropriate actions regarding their prescribed medications (warfarin and spinach intake, spironolactone and potassium intake, and calcium carbonate and water intake, respectively).

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