Nursing Elites

1. Which of the following statements indicates the client understands the colostomy care instructions?

• A. I will change the colostomy bag once a week.
• B. I will avoid eating high-fiber foods.
• C. I will clean around the stoma with mild soap and water.
• D. I will apply lotion to the skin around the stoma.

Correct answer: C

Rationale: The correct answer is C. Cleaning around the stoma with mild soap and water is crucial for colostomy care as it helps prevent infection and skin irritation. Changing the colostomy bag frequency, dietary modifications, or applying lotion are not primary aspects of stoma care. Proper cleaning around the stoma helps maintain hygiene and prevents complications, making it a key component of caring for a colostomy.

2. Which of the following dietary modifications should be recommended to a client with hypertension?

• A. Increase sodium intake.
• B. Reduce potassium intake.
• C. Increase fiber intake.
• D. Reduce calcium intake.

Correct answer: C

Rationale: Increasing fiber intake is a beneficial dietary modification for clients with hypertension. Fiber helps in reducing blood pressure and improving cardiovascular health by promoting better digestion and regulating cholesterol levels. Therefore, advising a client with hypertension to increase fiber intake can be beneficial for their overall health. In contrast, increasing sodium intake can lead to higher blood pressure, reducing potassium intake is not recommended as potassium helps in regulating blood pressure, and reducing calcium intake is not typically necessary for hypertension management.

3. A healthcare professional is preparing to administer an intramuscular (IM) injection to a client. Which of the following actions should the healthcare professional take?

• A. Use a 1-inch needle.
• B. Insert the needle at a 45-degree angle.
• C. Aspirate before injecting the medication.
• D. Administer the injection in the deltoid muscle.

Correct answer: C

Rationale: Aspirating before injecting the medication is a crucial step in IM injections to check for blood return, ensuring that the needle is not in a blood vessel. This technique helps prevent accidental intravascular injection of the medication, reducing the risk of complications such as inadvertent intravenous administration of the substance.

4. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30°
• B. Flush the tube with 50 mL of water every 2 hours
• C. Replace the feeding bag and tubing every 72 hours
• D. Check the client's gastric residual every 8 hours

Correct answer: A

Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.

5. A client has a new diagnosis of hypertension, and the nurse is teaching them about the DASH diet. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of sodium-rich foods.
• B. You should decrease your intake of potassium-rich foods.
• C. You should increase your intake of fruits and vegetables.
• D. You should decrease your intake of whole grains.

Correct answer: C

Rationale: The DASH diet, recommended for managing hypertension, emphasizes increasing the intake of fruits and vegetables. These food groups are rich in essential nutrients, fiber, and antioxidants, which can help lower blood pressure levels and promote overall cardiovascular health.

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