Nursing Elites

1. What is the most important aspect of colostomy care to teach the client?

• A. Change the colostomy bag only when necessary
• B. Eat a low-residue diet
• C. Assess the stoma for color and swelling
• D. Irrigate the colostomy only if advised by a healthcare provider

Correct answer: C

Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.

2. The nurse is teaching a client about the administration of a subcutaneous injection. Which site is most appropriate for this type of injection?

• A. Deltoid muscle
• B. Dorsogluteal muscle
• C. Ventrogluteal muscle
• D. Abdomen

Correct answer: D

Rationale: The abdomen is a common site for subcutaneous injections due to its accessibility and ample subcutaneous tissue. Subcutaneous injections are typically given in areas with a layer of fat between the skin and muscle, such as the abdomen, to allow for slow and consistent absorption of the medication. The deltoid muscle is more appropriate for intramuscular injections, not subcutaneous. The dorsogluteal muscle and ventrogluteal muscle are also more suited for intramuscular injections, not subcutaneous.

3. A postoperative client complains of sudden shortness of breath. What should the nurse do first?

• A. Administer oxygen
• B. Call the healthcare provider
• C. Prepare for chest x-ray
• D. Assess the client's lung sounds

Correct answer: D

Rationale: Assessing the client's lung sounds is the most appropriate initial action when a postoperative client complains of sudden shortness of breath. This step helps the nurse evaluate the respiratory status and detect abnormalities such as decreased breath sounds or crackles, which could indicate a serious condition like a pulmonary embolism. Administering oxygen (Choice A) may be necessary but should come after assessing the lung sounds to ensure the appropriate intervention. Calling the healthcare provider (Choice B) or preparing for a chest x-ray (Choice C) can be important subsequent actions based on the findings from the lung sound assessment, but they are not the first priority in this situation.

4. A grand multiparous client had a precipitous delivery in the emergency room 6 hours ago. The client was given oxytocin intramuscularly after birth. The nurse examines the client and observes the pad under her buttocks is full of blood. Which action should the nurse take first?

• A. Place a new pad and weigh the pad removed to determine blood loss.
• B. Massage the fundus and express clots.
• C. Start an IV and begin an oxytocin infusion.
• D. Clean the perineal area and encourage her to breastfeed.

Correct answer: B

Rationale: Massaging the fundus and expressing clots helps contract the uterus and reduce postpartum hemorrhage.

5. The nurse is assessing a newborn and notes that the infant has a yellowish tint to the skin. What should the nurse do next?

• A. Reassure the parents that this is normal
• B. Monitor the infant's bilirubin levels
• C. Increase the frequency of feedings
• D. Administer phototherapy

Correct answer: B

Rationale: When a newborn presents with a yellowish tint to the skin, it can indicate jaundice, which is caused by elevated bilirubin levels. Monitoring the infant's bilirubin levels is crucial to assess the severity of jaundice and determine the need for further intervention. Reassuring the parents without proper assessment could lead to delayed treatment if jaundice is present. Increasing the frequency of feedings may not address the underlying cause of jaundice. Administering phototherapy is a treatment option that should be based on bilirubin level assessment and healthcare provider's recommendation.

Similar Questions