Nursing Elites

1. The client with a new colostomy is being taught about colostomy care. Which statement by the client indicates effective learning?

• A. I will change my colostomy bag every day.
• B. I should eat a low-fiber diet.
• C. I need to inspect the stoma daily for color and swelling.
• D. I can skip my colostomy care if I feel well.

Correct answer: C

Rationale: The correct answer is C because inspecting the stoma daily is crucial in identifying any early signs of complications or infections. Choice A is incorrect because changing the colostomy bag daily is not necessary unless there is a specific reason to do so. Choice B is incorrect as a low-fiber diet is not usually recommended for colostomy care. Choice D is incorrect because colostomy care should be performed regularly regardless of how the client feels.

2. A client with a diagnosis of chronic heart failure is prescribed digoxin. What is the most important assessment before administering this medication?

• A. Check blood pressure
• B. Assess heart rate
• C. Monitor respiratory rate
• D. Measure oxygen saturation

Correct answer: B

Rationale: The correct answer is to assess the heart rate before administering digoxin. Digoxin can lead to bradycardia, making it crucial to evaluate the heart rate to prevent potential complications. Checking blood pressure (Choice A) is important but not as critical as assessing the heart rate in this context. Monitoring respiratory rate (Choice C) and measuring oxygen saturation (Choice D) are not the most crucial assessments before administering digoxin, as the primary concern with this medication is its impact on heart rate.

3. A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)

• A. Send wound drainage for culture and sensitivity.
• B. Institute contact precautions for staff and visitors.
• C. Use standard precautions and wear a mask.
• D. Monitor the client's white blood cell count.

Correct answer: B

Rationale: When dealing with a client suspected of having MRSA, the nurse should implement contact precautions to prevent the spread of infection. This includes using gowns and gloves, along with following proper hand hygiene practices. Sending wound drainage for culture and sensitivity may be necessary for diagnostic purposes, but it is not directly related to preventing the spread of infection in this case. Using standard precautions and wearing a mask are not sufficient when dealing with MRSA; contact precautions are specifically required to prevent transmission. Monitoring the client's white blood cell count is important in assessing infection status but is not a primary intervention to prevent the spread of MRSA.

4. What intervention should the nurse implement for a client experiencing an anxiety attack?

• A. Teach deep breathing exercises
• B. Provide a quiet environment
• C. Administer anxiolytic medication as prescribed
• D. Engage the client in conversation

Correct answer: C

Rationale: Administering prescribed anxiolytic medication is the most appropriate intervention for a client experiencing an anxiety attack. Anxiolytic medications can provide rapid relief from severe anxiety symptoms. Teaching deep breathing exercises (choice A) can be helpful for managing mild anxiety but may not be sufficient during an acute anxiety attack. Providing a quiet environment (choice B) is beneficial to reduce stimuli, but it may not address the immediate distress of an ongoing anxiety attack. Engaging the client in conversation (choice D) is generally not recommended during an anxiety attack as it can potentially exacerbate the symptoms by increasing stimulation.

5. A nurse is developing a care plan for a client with chronic pain. What interventions should be included to help manage pain?

• A. Administer pain medication around the clock
• B. Teach relaxation techniques
• C. Encourage physical activity
• D. All of the above

Correct answer: D

Rationale: In managing chronic pain, it is essential to employ a multi-faceted approach. Administering pain medication around the clock helps maintain consistent pain relief. Teaching relaxation techniques such as deep breathing or guided imagery can help reduce muscle tension and promote relaxation, which can alleviate pain. Encouraging physical activity, tailored to the client's abilities, can help improve overall physical functioning and reduce pain perception. Therefore, combining all these interventions (pain medication, relaxation techniques, and physical activity) provides a comprehensive approach to pain management, addressing different aspects of the client's experience with chronic pain. This holistic approach is more effective than using a single intervention alone, making 'All of the above' the correct choice.

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