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. The healthcare professional is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?

• A. Measuring the infant's length using a tape measure
• B. Weighing the infant on an electronic standing scale
• C. Measuring the chest circumference at the nipple line with a tape measure
• D. Measuring the head circumference by wrapping the tape measure around the head

Correct answer: C

Rationale: For accurate measurements, specific techniques are required for different parameters in infants. Measuring the chest circumference involves encircling the chest at the nipple line. Length should be measured on a horizontal measuring board. Weight should be measured using a platform-type balance scale. Head circumference measurement entails ensuring the tape is aligned at the eyebrows and prominent frontal and occipital bones for the widest span. Therefore, the correct technique for measuring the chest circumference is at the nipple line with a tape measure. The other options are incorrect because length should be measured on a horizontal board, weight should be measured on a balance scale, and head circumference should be measured around the head, not over the nose and cheekbones.

3. A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed but is unable to ambulate without help. What is the most appropriate safety measure?

• A. Restrain the client in bed
• B. Ask a family member to stay with the client
• C. Check the client every 15 minutes
• D. Use a bed exit safety monitoring device

Correct answer: D

Rationale: Option D is the most appropriate safety measure in this scenario. Using a bed exit safety monitoring device allows the client to retain some independence while ensuring that the nursing staff is alerted when assistance is needed. This solution promotes client safety without compromising their autonomy. Option A, restraining the client in bed, can lead to increased agitation, confusion, and a loss of independence. Option B, asking a family member to stay with the client, shifts the responsibility away from the healthcare team. Option C, checking the client every 15 minutes, is not a sufficient safety measure as the client could attempt to get out of bed in the unobserved interval, risking falls and injury.

4. What is the primary purpose of emergency planning?

• A. Comply with the laws of the state.
• B. Comply with the laws of the U.S.
• C. Comply with both state and U.S. laws
• D. Maintain safety

Correct answer: D

Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.

5. What is the MOST ACCURATE statement regarding the ESR test?

• A. The results are diagnostic for certain conditions.
• B. Abnormal results are indicative of a potentially fatal illness.
• C. Abnormal results should be followed by additional testing.
• D. Results are reported in millimeters per hour.

Correct answer: C

Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.

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