Nursing Elites

1. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:

• A. Increase the irrigating solution flow rate when abdominal cramps is felt
• B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
• C. Position client in semi-Fowler
• D. Hang the solution 18 inches above the stoma

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.

2. 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.

3. What describes a common physical change of aging that can affect an older adult's nutrition?

• A. reduced salivary output
• B. increased gastrointestinal motility
• C. abnormal cortisol production
• D. increase in number of taste buds

Correct answer: A

Rationale: Reduced salivary output is a common physical change in aging. This can affect an older adult's nutrition by impacting chewing, swallowing, and taste perception. The decrease in saliva production can make it harder to chew and swallow food effectively, affecting the overall eating experience. Additionally, saliva plays a role in taste perception, so a reduction in salivary output can lead to alterations in how food tastes, potentially impacting an individual's appetite and food choices. Increased gastrointestinal motility (choice B) is not typically associated with aging and would not directly affect nutrition. Abnormal cortisol production (choice C) is related to hormonal changes and is not a common physical change of aging that affects nutrition. An increase in the number of taste buds (choice D) is not a typical change associated with aging and would not have a significant impact on an older adult's nutrition.

4. A client with Crohn's disease is being cared for by a nurse. Which of the following food choices aligns with the recommended diet for clients with Crohn's disease?

• A. Vanilla milkshake
• B. Buttered popcorn
• C. Tossed green salad
• D. Toast with jelly

Correct answer: C

Rationale: The correct answer is a 'Tossed green salad.' Clients with Crohn's disease often benefit from a low-residue diet, which includes easily digestible foods like leafy green vegetables found in a tossed green salad. This type of diet helps minimize gastrointestinal symptoms. Choices A, B, and D are not ideal for clients with Crohn's disease. Vanilla milkshake, buttered popcorn, and toast with jelly may exacerbate symptoms due to their high fat, fiber, or sugar content, which can be harder to digest.

5. What is the first step in decontamination?

• A. Immediately applying a chemical decontamination foam to the area of contamination
• B. Thoroughly washing and rinsing the patient with soap and water
• C. Immediately applying personal protective equipment
• D. Removing the patient's clothing and jewelry, then rinsing the patient with water

Correct answer: D

Rationale: The correct first step in decontamination is to remove the patient's clothing and jewelry to prevent further exposure and then rinse the patient with water. This helps to eliminate any contaminants on the patient's body. Choice A is incorrect because applying a chemical decontamination foam should come after removing clothing. Choice B is incorrect as washing and rinsing the patient should follow the removal of clothing. Choice C is incorrect as personal protective equipment should be worn by the individual performing the decontamination, not applied to the patient.

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