Nursing Elites

1. A client with Crohn's disease is receiving parenteral nutrition. Which of the following interventions should the nurse not include in the care of this client?

• A. Remove the parenteral nutrition solution from the refrigerator 2 hours before infusion.
• B. Remove unused parenteral nutrition after 12 hours of use.
• C. Monitor daily laboratory values and report abnormalities as needed.
• D. Monitor the flow rate of the parenteral nutrition carefully and adjust it if necessary.

Correct answer: B

Rationale: In caring for a client receiving parenteral nutrition, it is important to follow proper guidelines to ensure safety and effectiveness. Unused parenteral nutrition should be removed after 24 hours, not 12 hours, to prevent contamination and reduce the risk of infection. Option A is correct as it ensures the solution is at room temperature before infusion. Option C is essential for monitoring the client's response to parenteral nutrition. Option D is important to maintain the correct flow rate and adjust it as needed. Therefore, option B is the incorrect choice among the options provided.

2. During the first 24 hours after the thermal injury, you should assess Sergio for:

• A. hypokalemia and hypernatremia
• B. hypokalemia and hyponatremia
• C. hyperkalemia and hyponatremia
• D. hyperkalemia and hypernatremia

Correct answer: D

Rationale: During the initial phase after a thermal injury, the major concern is the release of potassium due to cell damage, leading to hyperkalemia. Hypernatremia is not typically a primary concern in the immediate post-injury phase. Hyponatremia is less likely to occur initially after a burn injury. Therefore, the correct assessment for Sergio during the first 24 hours after the thermal injury would be hyperkalemia and hypernatremia.

3. What is tocopherol?

• A. Vitamin B1
• B. Vitamin B2
• C. Vitamin B3
• D. Vitamin E

Correct answer: D

Rationale: Tocopherol is another name for Vitamin E, a fat-soluble antioxidant that helps protect cell membranes from oxidative damage. Choices A, B, and C are incorrect as tocopherol is specifically related to Vitamin E and not Vitamin B1, B2, or B3.

4. The following mechanisms can be utilized as part of the quality assurance program of your hospital EXCEPT:

• A. Patient satisfaction surveys
• B. Peer review to assess care provided
• C. Review of clinical records of care of client
• D. Use of Nursing Interventions Classification

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.

5. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

• A. Pink, moist, and slightly protruding from the abdomen
• B. Gray, moist, and slightly protruding from the abdomen
• C. Pink, dry, and slightly protruding from the abdomen
• D. Red, moist, and slightly protruding from the abdomen

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

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