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 provider is caring for a client who has acute renal failure. Which of the following laboratory results should the healthcare provider expect?

• A. Decreased blood urea nitrogen (BUN)
• B. Decreased creatinine
• C. Increased potassium
• D. Increased calcium

Correct answer: C

Rationale: In acute renal failure, the kidneys are unable to excrete potassium efficiently, which can lead to hyperkalemia. As a result, an increased potassium level is a common finding in clients with acute renal failure. Hyperkalemia can have serious cardiac effects, making it essential for healthcare providers to monitor and manage potassium levels closely in clients with renal impairment. Choices A, B, and D are incorrect because in acute renal failure, blood urea nitrogen (BUN) and creatinine levels typically rise due to decreased renal function. Calcium levels are more likely to be decreased in acute renal failure due to impaired activation of vitamin D and subsequent decreased calcium absorption.

3. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

4. A client with hypertension is being taught about the DASH diet. Which of the following statements by the client indicates an understanding of the teaching?

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

Correct answer: C

Rationale: The correct answer is C. The Dietary Approaches to Stop Hypertension (DASH) diet is recommended for managing hypertension. Increasing the intake of fruits and vegetables is a key component of the DASH diet as these foods are rich in nutrients that can help lower blood pressure levels. Choices A, B, and D are incorrect because they go against the principles of the DASH diet, which focuses on reducing sodium intake, increasing potassium-rich foods, and consuming whole grains.

5. A client with a new diagnosis of hypertension is receiving teaching from a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will decrease my intake of potassium.
• B. I will increase my intake of vitamin K.
• C. I will decrease my intake of sodium.
• D. I will increase my intake of magnesium.

Correct answer: C

Rationale: The correct answer is C: 'I will decrease my intake of sodium.' Lowering sodium intake is essential in managing hypertension as it helps reduce blood pressure levels. Excess sodium can lead to fluid retention and increased blood volume, putting more strain on the heart and blood vessels. Therefore, this response indicates an understanding of the teaching provided. Choices A, B, and D are incorrect because decreasing potassium intake, increasing vitamin K intake, and increasing magnesium intake are not primary dietary modifications recommended for hypertension. While potassium and magnesium can be beneficial for overall health, reducing sodium intake is the key dietary change to manage hypertension effectively.

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