Nursing Elites

1. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?

• 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. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.

2. A nurse is caring for a client with a history of hypertension. Which of the following should the nurse monitor?

• A. Fluid intake
• B. Blood pressure
• C. Serum potassium levels
• D. Weight

Correct answer: B

Rationale: The correct answer is B: Blood pressure. When caring for a client with a history of hypertension, monitoring blood pressure is crucial as it allows the nurse to assess the effectiveness of management and adjust treatment if necessary. Monitoring fluid intake (Choice A) is important for conditions like heart failure, but in hypertension, the focus is primarily on blood pressure. Monitoring serum potassium levels (Choice C) is relevant in clients taking certain medications like diuretics, and weight (Choice D) is important for overall health assessment but is not the primary parameter to monitor in hypertension.

3. A healthcare professional is preparing to administer a hepatitis B vaccine. Which of the following should the healthcare professional verify?

• A. Client's allergy to eggs
• B. Client's vaccination history
• C. Client's weight
• D. Client's blood pressure

Correct answer: B

Rationale: The correct answer is B: Client's vaccination history. Before administering the hepatitis B vaccine, it is essential to verify the client's vaccination history to ensure they are due for the vaccine. This helps in preventing unnecessary vaccinations and ensures the appropriate timing and dosage. Option A, the client's allergy to eggs, is not directly related to administering the hepatitis B vaccine. Option C, the client's weight, and option D, the client's blood pressure, are not factors that need to be specifically verified before administering the hepatitis B vaccine.

4. A healthcare provider is assessing a client for allergies before administering propofol. Which of the following allergies is a contraindication to the medication?

• A. Eggs
• B. Milk
• C. Shrimp
• D. Peanuts

Correct answer: A

Rationale: The correct answer is A: Eggs. Propofol is contraindicated in clients with egg allergies because it contains egg lecithin, which can trigger allergic reactions in sensitive individuals. Milk, shrimp, and peanuts are not contraindications for propofol administration.

5. A nurse is caring for a client prescribed digoxin. Which of the following should alert the nurse to possible digitalis toxicity?

• A. Anorexia and weakness
• B. Hyperactivity and hunger
• C. Tachycardia and increased urination
• D. Polyphagia and polydipsia

Correct answer: A

Rationale: Corrected Rationale: Digitalis toxicity is a serious complication of digoxin therapy, particularly in older adults. Early symptoms include anorexia, nausea, and generalized weakness. Anorexia and weakness are common indicators of digitalis toxicity. Hyperactivity, hunger, tachycardia, increased urination, polyphagia, and polydipsia are not typical signs of digitalis toxicity. Monitoring for anorexia and weakness can help detect toxicity early and prevent life-threatening arrhythmias.

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