Nursing Elites

1. What should the nurse prioritize when providing discharge instructions to a client with a new colostomy?

• A. Skin care around the stoma site
• B. The schedule for colostomy bag replacement
• C. Techniques for odor control
• D. Dietary modifications

Correct answer: A

Rationale: Correct answer: Skin care around the stoma site. Proper skin care around the stoma site is crucial for preventing skin irritation and infection, which are common issues for patients with new colostomies. While the schedule for colostomy bag replacement (Option B) is important, it is not the priority during initial discharge instructions. Techniques for odor control (Option C) are relevant but secondary to skin care for a new colostomy. Dietary modifications (Option D) may be discussed later but are not the priority at this stage.

2. A client with heart failure is prescribed a low-sodium diet. The nurse notices the client's meal tray contains high-sodium foods. What action should the nurse take?

• A. Educate the client about the importance of a low-sodium diet
• B. Replace the meal with a low-sodium option
• C. Report the error to the dietary department
• D. Encourage the client to avoid eating the high-sodium foods

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to replace the high-sodium meal with a low-sodium option. This immediate intervention ensures that the client adheres to the prescribed low-sodium diet, crucial for managing heart failure and preventing fluid retention. Educating the client (Choice A) about the diet is important but not as urgent as ensuring they receive the correct meal. Reporting the error to the dietary department (Choice C) can be done after addressing the immediate issue. Encouraging the client to avoid high-sodium foods (Choice D) is not as effective as replacing the current meal with a suitable alternative.

3. The client has chronic renal failure. What dietary modification is most important for this client?

• A. Increase protein intake
• B. Limit potassium-rich foods
• C. Increase sodium intake
• D. Encourage dairy products

Correct answer: B

Rationale: Limiting potassium-rich foods is crucial in chronic renal failure to prevent hyperkalemia, which can lead to cardiac complications. Excessive protein intake can increase the workload on the kidneys and may result in the accumulation of uremic toxins. Increasing sodium intake is generally discouraged in chronic renal failure due to its association with hypertension and fluid retention. Encouraging dairy products may not be suitable for all clients with chronic renal failure, as they are a significant source of phosphorus, which needs to be limited in renal failure to prevent mineral imbalances.

4. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy protocol that includes methotrexate, an antimetabolite. Which information should the nurse provide the parents about caring for their child?

• A. Use sunblock or protective clothing when outdoors.
• B. Include the child in regular outings with the family.
• C. Obtain any childhood vaccinations that are not up-to-date.
• D. Use diluted commercial mouthwash for mouth care.

Correct answer: A

Rationale: The correct answer is to use sunblock or protective clothing when outdoors. Methotrexate can cause photosensitivity, making the child more prone to sunburns and skin damage. Therefore, advising the parents to protect their child's skin from direct sunlight exposure is crucial. Choice B is incorrect because exposing the child to direct sunlight without protection can worsen the photosensitivity caused by methotrexate. Choice C is incorrect as obtaining vaccinations is generally avoided during chemotherapy due to the child's compromised immune system. Choice D is incorrect as commercial mouthwash may contain alcohol, which can be irritating to the child's oral mucosa, especially during chemotherapy.

5. During a tonic-clonic seizure, what is the nurse's priority intervention?

• A. Insert an oral airway
• B. Administer oxygen via nasal cannula
• C. Restrain the client's arms and legs
• D. Protect the client's head from injury

Correct answer: D

Rationale: During a tonic-clonic seizure, the nurse's priority intervention is to protect the client's head from injury. This is crucial to prevent trauma, as head injuries can be severe during a seizure. Inserting an oral airway may cause injury or obstruction during the seizure and is not recommended. Administering oxygen via nasal cannula can be done after ensuring the client's safety. Restraining the client's arms and legs is also not recommended as it can lead to further injury or harm.

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