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. The healthcare provider is assessing a client who has just undergone a thyroidectomy. Which assessment finding is most concerning?

• A. Hoarseness of the voice
• B. Slight swelling at the incision site
• C. Tingling around the mouth
• D. Mild fever

Correct answer: C

Rationale: Tingling around the mouth is the most concerning finding as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common due to surgical manipulation, slight swelling at the incision site is expected postoperatively, and mild fever can be a normal inflammatory response. Hypocalcemia after thyroidectomy can lead to serious complications and should be addressed promptly to prevent further issues.

3. When teaching a client about managing hypertension, what dietary advice should be emphasized?

• A. Reduce sodium intake
• B. Increase potassium intake
• C. Limit alcohol consumption
• D. All of the above

Correct answer: D

Rationale: When managing hypertension, it is crucial to adopt comprehensive dietary changes. This includes reducing sodium intake to help lower blood pressure, increasing potassium intake to counteract the effects of sodium and help regulate blood pressure, and limiting alcohol consumption as excessive alcohol can raise blood pressure. Therefore, emphasizing all the options provided (A, B, and C) is essential in effectively managing hypertension and reducing overall cardiovascular risk. Choices A, B, and C are not individually sufficient as a single dietary modification but collectively work together to support blood pressure management.

4. The nurse is providing care for a client with a draining postoperative wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take?

• A. Encourage increased oral fluids.
• B. Provide high-protein snacks.
• C. Change the wound dressing.
• D. Administer prescribed antibiotics.

Correct answer: D

Rationale: Administering prescribed antibiotics is crucial in treating MRSA infections. MRSA is a type of bacteria that is resistant to many antibiotics, including methicillin. Therefore, prompt administration of the appropriate antibiotics is essential to target the MRSA infection effectively. Encouraging increased oral fluids (Choice A) and providing high-protein snacks (Choice B) may be beneficial for overall recovery but are not the most important actions in treating an MRSA infection. Changing the wound dressing (Choice C) is important for wound care but does not directly address the infection caused by MRSA.

5. The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take?

• A. Ask the client why the bath was refused
• B. Ask family members to encourage the client to bathe
• C. Explain the importance of good hygiene to the client
• D. Reschedule the bath for the following day

Correct answer: A

Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reasons for refusal can guide appropriate interventions, respecting client autonomy while addressing any underlying issues. Choice B is not the best course of action as involving family members may not address the client's specific concerns. Choice C, while important, may not directly address the immediate refusal to bathe. Choice D does not address the underlying reasons for the refusal and may not lead to a resolution.

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