Nursing Elites

1. A patient has suffered a left CVA and developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema, and the skin is intact. The nurse should score the patient as having which of the following?

• A. Stage I pressure ulcer
• B. Stage II pressure ulcer
• C. Stage III pressure ulcer
• D. Stage IV pressure ulcer

Correct answer: A

Rationale: Erythema with the skin intact is characteristic of a Stage I pressure ulcer. At this stage, the skin is not broken, but there is localized redness that does not blanch when pressed. Stage II pressure ulcers involve partial-thickness skin loss, Stage III pressure ulcers have full-thickness skin loss, and Stage IV pressure ulcers extend to deeper tissues, including muscle and bone. In this case, the non-blanchable erythema with intact skin aligns with the characteristics of a Stage I pressure ulcer.

2. A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?

• A. Verbal teaching in short sessions throughout the day
• B. Provide a pre-operative booklet in Braille
• C. Provide an audio recording for the client
• D. Have the blind patient's family member assist with the instruction

Correct answer: A

Rationale: For a blind patient scheduled for surgery the following morning, the best teaching strategy would be verbal teaching in short sessions throughout the day. Providing information in smaller amounts makes it easier to retain, and one-on-one teaching is most effective. Choice B, providing a pre-operative booklet in Braille, may not be as practical for last-minute teaching. Choice C, providing an audio recording, may not allow for immediate interaction and clarification. Choice D, having a family member instruct the patient, may not ensure the accuracy and clarity of the information provided.

3. The client seeks advice from the nurse regarding issues with flatus due to colostomy. Which food should the nurse recommend?

• A. High-fiber foods, such as bran.
• B. Cruciferous vegetables, such as cabbage, broccoli, and kale.
• C. Carbonated beverages.
• D. Yogurt.

Correct answer: D

Rationale: The correct answer is yogurt. Yogurt can help reduce gas formation in clients with a colostomy. High-fiber foods like bran can stimulate peristalsis and increase flatulence, which is not helpful in this situation. Cruciferous vegetables, such as cabbage, broccoli, and kale, and beans tend to increase gas formation. Carbonated beverages, along with smoking, chewing gum, and drinking fluids with a straw, can also increase gas formation. Therefore, the nurse should recommend yogurt to help alleviate the client's issues with flatus.

4. Which of the following organs of the digestive system has a primary function of absorption?

• A. stomach
• B. pancreas
• C. small intestine
• D. gallbladder

Correct answer: C

Rationale: The small intestine is the correct answer. It is the primary organ responsible for absorption in the digestive system. The stomach's primary function is to break down food through mechanical and chemical digestion. The pancreas produces digestive enzymes to aid in the breakdown of food. The gallbladder stores bile produced by the liver, which helps in the digestion of fats. However, neither the stomach, pancreas, nor gallbladder play the primary role of absorption in the digestive process, making them incorrect choices.

5. The client is preparing to learn about the effects of isoniazid (INH). Which information is essential for the client to understand?

• A. Isoniazid should be taken with meals to reduce gastrointestinal upset.
• B. Prolonged use of isoniazid may result in dark, concentrated urine.
• C. Taking aluminum hydroxide (Maalox) with isoniazid can enhance the drug's effects.
• D. Consuming alcohol daily can increase the risk of drug-induced hepatitis.

Correct answer: D

Rationale: It is crucial for the client to understand that consuming alcohol while on isoniazid can increase the risk of drug-induced hepatitis. Hepatic damage can lead to dark, concentrated urine. To minimize gastrointestinal upset, it is recommended to take isoniazid with meals rather than on an empty stomach. Additionally, the client should avoid taking aluminum-containing antacids like aluminum hydroxide with isoniazid, as it can reduce the drug's effectiveness. Choice A is incorrect because isoniazid should not be taken on an empty stomach to help reduce GI upset. Choice B is incorrect, as prolonged use of isoniazid does not typically cause dark, concentrated urine. Choice C is incorrect as taking aluminum hydroxide with isoniazid does not enhance the drug's effects; in fact, it may decrease its effectiveness.

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