Nursing Elites

1. Which of the following statements is true about ischemic colitis?

• A. Typically requires colonic resection
• B. Affects the watershed areas of the colon, namely, the splenic flexure, right colon, and rectum
• C. Is only seen in the elderly
• D. Requires colonoscopic intervention

Correct answer: B

Rationale: Ischemic colitis most often results from low-flow states associated with hypotension or poor perfusion. As a result, the vascular watershed areas of the colon, including the splenic flexure, right colon, and rectum, are at highest risk of ischemic injury. Therefore, option B is correct as it accurately identifies the areas commonly affected by ischemic colitis.

2. A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has 'little reason to live.' She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement?

• A. Encourage the client to remove the gun from her possession.
• B. Notify the client's healthcare provider of the availability of the weapon.
• C. Contact a person of the client's choosing to remove the weapon from the home.
• D. Call the local police department and have the weapon removed from the home.

Correct answer: C

Rationale: In this scenario, it is crucial to maintain the client's confidentiality while ensuring her safety. Contacting a person chosen by the client to remove the weapon from her home is the best course of action. This approach respects the client's autonomy and helps reduce the risk of harm without involving external authorities unnecessarily.

3. The client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?

• A. Discontinue the IV and apply pressure at the site.
• B. Decrease the saline to a keep-open rate.
• C. Increase the rate of the current IV solution.
• D. Change the IV fluid to 0.45% normal saline at the same rate.

Correct answer: B

Rationale: In this scenario, the client is showing signs of fluid overload with tachypnea and a high pulse rate. Decreasing the saline to a keep-open rate is appropriate to prevent further fluid volume excess. This action allows for IV access to be maintained while reducing the fluid administered, helping to manage the symptoms of fluid overload.

4. The healthcare provider is providing care to a client with a tracheostomy. Which action should the healthcare provider take to prevent tracheostomy complications?

• A. Use sterile technique when performing tracheostomy care.
• B. Suction the tracheostomy tube every hour.
• C. Keep the tracheostomy tube cuff inflated at all times.
• D. Change the tracheostomy ties daily.

Correct answer: A

Rationale: Using sterile technique when performing tracheostomy care is essential to prevent infections and other complications. Proper sterile technique helps reduce the risk of introducing harmful bacteria into the tracheostomy site, which can lead to infections and other serious issues. By maintaining a sterile environment during tracheostomy care, the healthcare provider can promote healing and prevent potential complications.

5. When working with a client who has chronic constipation, what should be included in client teaching to promote normal bowel function?

• A. Use glycerin suppositories on a regular basis
• B. Limit physical activity in order to promote bowel peristalsis
• C. Consume high-residue, high-fiber foods
• D. Resist the urge to defecate until the urge becomes intense

Correct answer: C

Rationale: Consuming high-residue, high-fiber foods is essential in promoting normal bowel function and preventing constipation. These foods help add bulk to the stool, making it easier to pass and preventing constipation. Glycerin suppositories may provide short-term relief but are not a long-term solution for chronic constipation. Physical activity actually helps promote bowel peristalsis, so limiting it would not be beneficial. Delaying defecation can lead to stool hardening and worsening constipation.

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