Nursing Elites

1. The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage?

• A. Place a 4x4 wick in the stoma opening
• B. Apply a layer of zinc oxide ointment to the perimeter of the stoma
• C. Cut the bag opening to the measurement of the stoma size
• D. Administer a PRN antidiarrheal agent

Correct answer: C

Rationale: To prevent leakage of stool under the disposable ostomy bag, the nurse should cut the bag opening to the measurement of the stoma size. This action ensures a proper fit, which is crucial in preventing leaks that can lead to skin irritation and compromise stoma care. Placing a 4x4 wick in the stoma opening or applying zinc oxide ointment may not address the issue of leakage effectively. Administering a PRN antidiarrheal agent is not directly related to preventing leakage caused by an ill-fitting ostomy bag.

2. 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.

3. The healthcare provider is preparing to administer an intramuscular injection to an adult client. Which site is the preferred location for this injection?

• A. Deltoid muscle.
• B. Vastus lateralis muscle.
• C. Ventrogluteal muscle.
• D. Dorsogluteal muscle.

Correct answer: C

Rationale: The ventrogluteal site is preferred for intramuscular injections in adults due to its muscle mass and lower risk of nerve injury. The deltoid muscle is more commonly used for vaccines in adults, the vastus lateralis muscle is preferred in infants and young children, and the dorsogluteal muscle is associated with a higher risk of nerve injury and is no longer recommended for intramuscular injections.

4. The nurse is assessing a client with congestive heart failure who is receiving furosemide (Lasix). Which laboratory value should the nurse monitor closely?

• A. Sodium level
• B. Potassium level
• C. Calcium level
• D. Chloride level

Correct answer: B

Rationale: The correct answer is B: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring the potassium level is crucial to prevent complications such as cardiac arrhythmias. Sodium level (choice A) is not typically affected by furosemide. Calcium level (choice C) and chloride level (choice D) are also not the primary focus of monitoring when a client is on furosemide for heart failure.

5. The nurse is in charge of a Nursing unit in a long-term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients?

• A. Measure the amount of a client's residual urine after voiding
• B. Cleanse the perineal area of a client with urinary incontinence
• C. Insert a straight catheter to obtain a urine specimen for culture
• D. Provide catheter care for a client with a suprapubic catheter

Correct answer: B

Rationale: The correct answer is B because cleaning the perineal area is a task within the scope of practice for unlicensed assistive personnel (UAPs) and is crucial for preventing infections. Choice A involves a more complex task that requires a healthcare provider's assessment. Choice C involves a sterile procedure that should be performed by licensed staff. Choice D involves specific care for a client with a catheter that exceeds the UAP's scope of practice.

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