Nursing Elites

1. A nurse is caring for a client with a new colostomy. Which instruction should the nurse include in the client's teaching plan?

• A. Change the ostomy appliance daily
• B. Empty the ostomy pouch when it is one-third full
• C. Rinse the ostomy pouch with warm water
• D. Apply a skin barrier to the peristomal skin

Correct answer: B

Rationale: The correct instruction the nurse should include in the client's teaching plan is to empty the ostomy pouch when it is one-third full. This practice helps prevent leakage and skin irritation by maintaining an appropriate pouching system. Changing the ostomy appliance daily (Choice A) is not necessary unless leakage or other issues occur. Rinsing the ostomy pouch with warm water (Choice C) is not a recommended practice as it may cause damage to the pouch. Applying a skin barrier to the peristomal skin (Choice D) is important but not the most crucial instruction in this scenario.

2. The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client’s plan of care?

• A. Monitor serum calcium levels
• B. Obtain a baseline electrocardiogram
• C. Implement seizure precautions
• D. Encourage a low-protein diet

Correct answer: C

Rationale: The correct answer is to implement seizure precautions. Phenytoin is an antiepileptic medication used for seizure control. Seizure precautions are crucial for clients taking this medication to ensure their safety during a seizure episode. Monitoring serum calcium levels (Choice A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (Choice B) is important for some medications but not the priority for a client on phenytoin. Encouraging a low-protein diet (Choice D) is not specifically indicated for clients on phenytoin and is not the most important intervention.

3. A client with cirrhosis is taking lactulose (Cephulac). Which finding indicates that the lactulose is having the desired effect?

• A. Two to three soft bowel movements per day
• B. Increased serum ammonia levels
• C. Decreased white blood cell count
• D. Soft, formed stool twice a day

Correct answer: A

Rationale: The correct answer is A: 'Two to three soft bowel movements per day.' Lactulose is prescribed to produce soft, regular bowel movements to reduce ammonia levels in clients with cirrhosis. This helps in preventing hepatic encephalopathy. Option B is incorrect because increased serum ammonia levels would indicate that lactulose is not effectively reducing ammonia levels. Option C is incorrect because lactulose does not directly affect white blood cell counts. Option D is incorrect because soft, formed stools twice a day may not be frequent enough to effectively reduce ammonia levels in clients with cirrhosis.

4. A client who is 32-weeks pregnant is diagnosed with partial placenta previa. Which instruction should the nurse include in this client’s teaching plan?

• A. Wear a tight abdominal binder at all times
• B. Take a daily laxative to prevent constipation
• C. Refrain from sexual intercourse until your next appointment
• D. Restrict fluids to less than 1000 ml per day

Correct answer: C

Rationale: Refraining from sexual intercourse helps prevent complications with partial placenta previa.

5. The nurse is performing a physical assessment of a client with a history of smoking and notes a barrel chest. Which action is most important for the nurse to take next?

• A. Assess the client's oxygen saturation level
• B. Teach the client pursed-lip breathing techniques
• C. Determine the client's history of lung disease
• D. Obtain an arterial blood gas sample

Correct answer: A

Rationale: Corrected Rationale: Assessing the client's oxygen saturation level is crucial when a nurse identifies a barrel chest. A barrel chest is often associated with chronic obstructive pulmonary disease (COPD), which can lead to impaired gas exchange and decreased oxygen saturation. Monitoring the oxygen saturation level will provide immediate information on the client's respiratory status. Teaching pursed-lip breathing techniques, determining lung disease history, and obtaining arterial blood gas samples are important interventions but assessing oxygen saturation takes precedence in this scenario due to its direct impact on the client's respiratory function.

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