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. Which of the following is NOT an acceptable abbreviation?

• A. D/C
• B. tid
• C. bid
• D. qid

Correct answer: A

Rationale: The correct answer is A: D/C. D/C is not an acceptable abbreviation as it can be easily confused with both 'discharge' and 'discontinue.' The abbreviations 'tid' (three times a day), 'bid' (twice a day), and 'qid' (four times a day) are commonly used in medical contexts to indicate dosing frequencies and are widely accepted in healthcare settings.

3. A client is about to have a TENS unit attached for pain relief. Which of the following actions is most appropriate in this situation?

• A. Inform the client that he may experience tingling sensations.
• B. Connect the TENS unit before the client goes to bed for the night.
• C. Inform the client that the TENS unit may have pain-reducing effects for 10 to 15 days.
• D. After treatment, inform the client that he may not use a TENS unit again for at least 2 weeks.

Correct answer: A

Rationale: When attaching a TENS unit for pain relief, it is essential to inform the client that he may experience tingling sensations. This is a common sensation experienced when using a TENS unit, but it should not cause muscle twitching. The therapeutic effects of a TENS unit usually last between 3 to 5 days. Choice B is incorrect because there is no specific recommendation to connect the TENS unit before bedtime. Choice C is incorrect as stating that the TENS unit may have pain-reducing effects for 10 to 15 days is inaccurate, as the effects typically last 3 to 5 days. Choice D is incorrect because there is no guideline suggesting that the client cannot use a TENS unit again for at least 2 weeks after treatment.

4. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?

• A. The client's IV is infiltrated
• B. The client is experiencing phlebitis from the last drug administered
• C. The client has a blood clot developing in the distal arteries of the wrist
• D. The client's pain is associated with myocardial ischemia and he is having a heart attack

Correct answer: A

Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.

5. 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.

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