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. Discharge plans of diabetic clients include injection site rotation. You should emphasize that the space between sites should be:

• A. 6.0 cm.
• B. 5.0 cm.
• C. 2.5 cm.
• D. 4.0 cm.

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. What is the absorbable unit of a protein?

• A. Amino acid
• B. Pepsin
• C. Glucose
• D. Sucrose

Correct answer: A

Rationale: Amino acids are the correct answer because they are the building blocks of proteins that the body absorbs after digestion. Pepsin, choice B, is incorrect as it is an enzyme that aids in the digestion of proteins, not the absorbable unit of them. Choices C and D, glucose and sucrose, are wrong because they are types of sugars, not proteins.

4. Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?

• A. Self-esteem disturbance
• B. Impaired urinary elimination
• C. Impaired skin integrity
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.

5. Mang David, A 27 year old psychiatric client was admitted with a diagnosis of schizophrenia. During the morning assessment, Mang David shouted “Did you know that I am the top salesman in the world? Different companies want me!” As a nurse, you know that this is an example of:

• A. Hallucination
• B. Delusion
• C. Confabulation
• D. Flight of Ideas

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.

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