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. A healthcare professional is supervising a newly licensed colleague who is preparing to administer an intramuscular injection. Which of the following actions by the newly licensed colleague requires intervention?

• A. Selecting a 25-gauge needle
• B. Administering the injection at a 45° angle
• C. Using the ventrogluteal site for the injection
• D. Aspirating for blood return before injecting the medication

Correct answer: B

Rationale: The correct answer is B. Administering an intramuscular injection at a 90° angle is essential for proper medication delivery into the muscle tissue. Injecting at a 45° angle is incorrect for intramuscular injections and is typically used for subcutaneous injections where the needle is inserted into the fatty tissue layer beneath the skin. Choice A is correct as selecting a 25-gauge needle is appropriate for an intramuscular injection. Choice C is also correct as the ventrogluteal site is a suitable site for intramuscular injections. Choice D is correct as aspirating for blood return is a necessary step to ensure the needle is not in a blood vessel before injecting the medication.

3. A client with a new diagnosis of pancreatitis is being taught about dietary management. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of high-fat foods.
• B. You should decrease your intake of high-fat foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of dairy products.

Correct answer: B

Rationale: The correct statement the nurse should include in teaching a client with pancreatitis is to decrease the intake of high-fat foods. This dietary modification is crucial in managing symptoms and preventing exacerbations of pancreatitis. High-fat foods can put a strain on the pancreas, potentially leading to further complications. Choice A is incorrect because increasing intake of high-fat foods can worsen pancreatitis. Choice C is unrelated to pancreatitis management, as lactose intolerance is not directly linked to pancreatitis. Choice D is also incorrect, as increasing dairy product intake may not be suitable for all individuals with pancreatitis due to the fat content in many dairy products.

4. A client has a new diagnosis of hypertension and is being taught about dietary management. Which of the following statements should be included by the healthcare provider?

• A. Increase your intake of sodium-rich foods.
• B. Decrease your intake of sodium-rich foods.
• C. Avoid foods that contain lactose.
• D. Increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is B: 'Decrease your intake of sodium-rich foods.' When managing hypertension, reducing the intake of sodium-rich foods is essential. Excessive sodium can contribute to increased blood pressure, which is why limiting its consumption is crucial to prevent complications. Choices A, C, and D are incorrect. Increasing sodium intake would exacerbate hypertension, avoiding lactose is unrelated to managing hypertension, and increasing dairy product intake does not specifically address the issue of sodium intake in hypertension management.

5. A client has a stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?

• A. Apply a heat lamp to the area for 20 minutes each day.
• B. Change the dressing on the heel every 12 hours.
• C. Apply a transparent dressing over the heel.
• D. Use a water pressure mattress.

Correct answer: C

Rationale: Applying a transparent dressing over the heel is beneficial as it can protect the ulcer from friction and shear, and allow for continuous observation of the wound. This intervention promotes healing and prevents further damage to the skin. Choice A is incorrect because applying heat can increase the risk of tissue damage and should be avoided. Choice B is incorrect as changing the dressing every 12 hours may disrupt the wound healing process and is not necessary for a stage 1 pressure ulcer. Choice D is incorrect because using a water pressure mattress is not a specific intervention for a stage 1 pressure ulcer on the heel.

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