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 caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. International normalized ratio (INR)
• D. Activated partial thromboplastin time (aPTT)

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). While INR is commonly used to monitor the effectiveness of warfarin therapy, in the case of heparin therapy, the Partial Thromboplastin Time (PTT) is the preferred test. Choice A, Prothrombin Time (PT), measures the activity of the extrinsic pathway of coagulation and is not the best choice for monitoring heparin therapy. Choice D, Activated Partial Thromboplastin Time (aPTT), is similar to PTT and is used to monitor heparin therapy, but PTT is the more specific test. Therefore, monitoring PTT is crucial in determining the effectiveness and safety of heparin therapy.

3. When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement?

• A. Instill the medication quickly
• B. Insert the needle slowly
• C. Select a large, deep muscle mass
• D. Use a short, small gauge needle

Correct answer: C

Rationale: The correct answer is C: Select a large, deep muscle mass. When administering an intramuscular injection with a painful medication volume of 3 ml, selecting a large and deep muscle mass is crucial. This intervention reduces discomfort for the patient and ensures proper absorption of the medication. Choice A is incorrect because instilling the medication quickly can increase discomfort. Choice B is incorrect as inserting the needle slowly may prolong the discomfort. Choice D is incorrect as using a short, small gauge needle may not be suitable for delivering 3 ml of medication effectively into the muscle.

4. In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?

• A. Measure the client's oxygen saturation before taking further action
• B. Administer a PRN dose of nitroglycerin (Nitrostat)
• C. Administer the dose of furosemide as scheduled
• D. Hold the dose of furosemide until contacting the healthcare provider

Correct answer: C

Rationale: Administering the scheduled dose of furosemide is appropriate when a client with heart failure has an elevated BNP level. BNP elevation indicates fluid overload, and furosemide is a diuretic that helps in reducing excess fluid. Measuring the client's oxygen saturation (Choice A) is not directly related to addressing fluid overload. Administering nitroglycerin (Choice B) is not indicated for managing elevated BNP levels. Holding the furosemide dose (Choice D) would delay appropriate treatment for fluid overload.

5. The nurse is caring for a client who is 2 days post-op following an abdominal hysterectomy. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps to cover and protect the exposed bowel, preventing infection and maintaining a moist environment for wound healing. Option B, notifying the healthcare provider, is important but should come after addressing the immediate need of covering the wound. Administering pain medication (option C) and covering the wound with an abdominal binder (option D) are not appropriate initial actions for this situation.

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