Nursing Elites

1. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers?

• A. Apply liberal amount of mineral oil to the area
• B. Use karaya paste and rings around the stoma
• C. Clean the area daily with soap and water before applying bag
• D. Apply talcum powder twice a day

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

2. During the detoxification stage, it is a priority for the nurse to:

• A. teach skills to recognize and respond to health threatening situations
• B. increase the client’s awareness of unsatisfactory protective behaviors
• C. implement behavior modification
• D. promote homeostasis and minimize the client’s withdrawal symptoms

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

• A. Pink, moist, and slightly protruding from the abdomen
• B. Gray, moist, and slightly protruding from the abdomen
• C. Pink, dry, and slightly protruding from the abdomen
• D. Red, moist, and slightly protruding from the abdomen

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

4. Vitamin deficiencies, especially the B-complex vitamins, seldom occur in isolation. Folate, a B-complex vitamin, is the exception because it functions separately from other vitamins.

• A. Both statements are true.
• B. Both statements are false.
• C. The first statement is true; the second is false.
• D. The first statement is false; the second is true.

Correct answer: C

Rationale: The first statement is true; the second is false. If a deficiency of one vitamin is suspected, symptoms of other vitamin B deficiencies also may be present. Folate deficiencies usually occur with other nutrient deficiencies. Specifically, folate functions in conjunction with vitamins B12 and C in maintaining normal levels of mature red blood cells.

5. In kidney disease, which mineral should a patient limit intake of?

• A. Calcium
• B. Magnesium
• C. Phosphorus
• D. Potassium

Correct answer: C

Rationale: In kidney disease, patients are advised to limit the intake of phosphorus. High levels of phosphorus can be problematic as the kidneys may not be able to effectively filter it out, leading to bone health issues. Calcium (Choice A) is important for bone health, but its restriction is not typically necessary in kidney disease. Magnesium (Choice B) and potassium (Choice D) restrictions may be required in certain cases of kidney disease, but phosphorus is the mineral most commonly limited due to its impact on bone health.

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