Nursing Elites

1. A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states:

• A. I will make sure my medications are enteric-coated
• B. My stoma will drain liquid continuously
• C. I will change my pouch system every two weeks
• D. My stoma size will stay the same after it heals

Correct answer: B

Rationale: The correct answer is B. When a client with an ileostomy states that their stoma will drain liquid continuously, it indicates an understanding of the expected outcome. In an ileostomy, the stoma continuously drains liquid stool as it bypasses the large intestine where water is absorbed. Choices A, C, and D are incorrect because ensuring medications are enteric-coated, changing the pouch system every two weeks, and expecting the stoma size to remain the same after healing are not accurate statements related to an ileostomy.

2. A patient scheduled for cataract surgery tells the nurse, 'I see just fine and have decided to cancel my surgery.' Which response should the nurse make?

• A. Tell the patient they need the surgery
• B. Encourage the patient to express their thoughts
• C. Ignore the comment and proceed
• D. Insist the patient needs to proceed with the surgery

Correct answer: B

Rationale: Encouraging the patient to express their thoughts is the best response in this situation. It allows the patient to voice their concerns or reasons for canceling the surgery, which can help the healthcare team address any misunderstandings or fears the patient may have. Choices A and D are too directive and do not consider the patient's autonomy and right to make informed decisions about their care. Choice C is inappropriate as it disregards the patient's expressed decision and fails to address the underlying issue.

3. A nurse is preparing to administer a dose of furosemide. Which of the following should the nurse do before administration?

• A. Check potassium levels
• B. Assess blood glucose levels
• C. Monitor respiratory rate
• D. Administer with food

Correct answer: A

Rationale: The correct answer is to check potassium levels before administering furosemide. Furosemide is a diuretic that can cause hypokalemia (low potassium levels) as a side effect. Monitoring potassium levels is crucial to prevent potential complications related to electrolyte imbalance. Assessing blood glucose levels (choice B) is not directly related to furosemide administration. Monitoring respiratory rate (choice C) is important in certain situations, but it is not the priority before administering furosemide. Administering furosemide with food (choice D) is not a requirement as it can be administered regardless of meals.

4. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?

• A. Nausea and vomiting
• B. Increased urination
• C. Tremors
• D. Blurred vision

Correct answer: C

Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.

5. A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?

• A. We will place the baby on its back to sleep
• B. We will give the baby a pacifier at bedtime
• C. We will keep the baby's crib free of blankets and toys
• D. We will leave the baby's diaper off to prevent diaper rash

Correct answer: D

Rationale: The correct answer is D. Leaving the baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash. Choices A, B, and C are correct as placing the baby on its back to sleep, giving the baby a pacifier at bedtime, and keeping the baby's crib free of blankets and toys are appropriate measures to ensure the newborn's safety and reduce the risk of Sudden Infant Death Syndrome (SIDS).

Similar Questions