Nursing Elites

1. A client is preparing to irrigate a colostomy. Which of the following situations is a contraindication for this type of irrigation?

• A. The client has an incontinent ostomy
• B. The client has an irregular bowel routine
• C. The client has diverticulitis
• D. The colostomy bag contains fecal material

Correct answer: C

Rationale: When a client with a colostomy is preparing for irrigation, it is essential to consider contraindications that could pose risks or worsen the client's condition. Diverticulitis is a contraindication for colostomy irrigation because the inflamed diverticula could be further irritated by the flushing action during irrigation, potentially leading to complications. An incontinent ostomy, irregular bowel routine, or presence of fecal material in the colostomy bag are not specific contraindications for irrigation and can be managed through appropriate techniques and interventions.

2. Specific gravity in urinalysis:

• A. compares the concentration of urine to that of distilled water
• B. is useless when the patient is dehydrated
• C. can only be measured using a refractometer
• D. None of the above

Correct answer: A

Rationale: Specific gravity in urinalysis measures the concentration of solutes in urine compared to that of distilled water. This comparison helps in assessing the kidney's ability to concentrate urine properly. It is a valuable test even in dehydrated patients as it provides insights into renal function. Specific gravity can be measured using various methods, including a refractometer or reagent strips. Normal specific gravity readings of human urine typically range from 1.005 to 1.030. Choice A is correct as it accurately describes the purpose of specific gravity in urinalysis. Choices B and C are incorrect as specific gravity remains relevant in dehydrated patients and can be measured using different techniques, not solely a refractometer.

3. Which of the following items of subjective client data would be documented in the medical record by the nurse?

• A. Client's face is pale
• B. Cervical lymph nodes are palpable
• C. Nursing assistant reports client refused lunch
• D. Client feels nauseated

Correct answer: D

Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition. Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse. Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.

4. Nursing care plans are _______________?

• A. written by CNAs before they provide care
• B. guidelines of care that all nursing team members use
• C. used by nurses but not by nursing assistants
• D. used by nursing assistants but not by nurses

Correct answer: B

Rationale: Nursing care plans are comprehensive documents created by registered nurses to outline individualized care for patients. These plans serve as guidelines for all members of the nursing team, including nursing assistants, to ensure consistent and quality care. Choice A is incorrect as CNAs typically assist in implementing the care plan rather than creating it. Choice C is incorrect as nursing care plans are utilized by all members of the nursing team, not exclusive to only nurses. Choice D is incorrect as nursing assistants also utilize nursing care plans to provide patient care effectively.

5. When assessing the pulse of a 6-year-old patient, the nurse notices that the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action would the nurse take next?

• A. Notify the physician.
• B. Record this finding as normal.
• C. Check the child's blood pressure and note any variation with respiration.
• D. Document that this child has bradycardia and continue with the assessment.

Correct answer: B

Rationale: The correct action for the nurse to take next is to record this finding as normal. Sinus dysrhythmia, characterized by heart rate variation with the respiratory cycle, is commonly found in children and young adults. The heart rate speeds up at the peak of inspiration and slows to normal with expiration. This phenomenon is a normal variant and does not require any intervention. There is no need to notify the physician as this finding is within the expected range for this age group. Checking the child's blood pressure for variations with respiration or documenting the child as having bradycardia would not be appropriate in this case, as sinus dysrhythmia is a normal physiological response.

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