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 preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?

• A. Use sterile gloves only as necessary
• B. Restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray
• C. Keep the dressing tray on a nearby surface
• D. Avoid speaking during the procedure

Correct answer: B

Rationale: The correct action to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray. Any contact with the sterile field by non-sterile items makes the field contaminated and requires restarting the procedure to maintain sterility. Choice A is incorrect because sterile gloves should always be used during a sterile procedure to prevent contamination. Choice C is incorrect as the dressing tray should be placed on a sterile surface, not on the client's bed, to maintain sterility. Choice D is also incorrect as talking during the procedure does not necessarily lead to contamination if proper aseptic technique is maintained.

3. 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.

4. During triage following a mass casualty event, which client should be prioritized?

• A. A client with massive head trauma
• B. A client with full-thickness burns to the face and trunk
• C. A client showing signs of hypovolemic shock
• D. A client with an open fracture of the lower extremity

Correct answer: C

Rationale: During triage after a mass casualty event, the client showing signs of hypovolemic shock should be prioritized. Hypovolemic shock is a life-threatening condition that requires immediate attention to restore circulation and prevent death. While clients with head trauma, burns, and fractures also need urgent care, hypovolemic shock poses an immediate threat to life and must be addressed first to stabilize the client's condition.

5. A nurse is assessing a 2-hour-old newborn for cold stress. Which of the following findings should the nurse expect?

• A. Respiratory rate of 60/min
• B. Jitteriness of the hands
• C. Diaphoresis
• D. Bounding peripheral pulses

Correct answer: B

Rationale: The correct answer is B: Jitteriness of the hands. Jitteriness is a key sign of cold stress in a newborn, indicating the need for immediate warming measures. A respiratory rate of 60/min may not be directly indicative of cold stress. Diaphoresis (excessive sweating) and bounding peripheral pulses are not typical findings associated with cold stress in newborns.

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