Nursing Elites

1. The preferred route of administration of medication in the most acute care situations is which of the following routes?

• A. Intravenous C. Subcutaneous
• B. Epidural D. Intramuscular
• C.
• D.

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

• A. Pink, moist, and slightly protruding from the abdomen
• B. Gray, moist, and slightly protruding from the abdomen
• C. Pink, dry, and slightly protruding from the abdomen
• D. Red, moist, and slightly protruding from the abdomen

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

3. Mr. Bruno asks what the “normal” allowable salt intake is. Your best response to Mr. Bruno is:

• A. 1 tsp of salt/day with iodine and sprinkle of MSG
• B. 5 gms per day or 1 tsp of table salt/day
• C. 1 tbsp of salt/day with some patis and toyo
• D. 1 tsp of salt/day but no patis and toyo

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

4. After bronchoscopy, the nurse's priority is to check which of the following before feeding?

• A. Gag reflex
• B. Wearing off of anesthesia
• C. Swallowing reflex
• D. Peristalsis

Correct answer: A

Rationale: After a bronchoscopy procedure, the nurse's priority is to check the patient's gag reflex before allowing them to eat to prevent aspiration. The gag reflex helps protect the airway by triggering a cough or gag response if something touches the back of the throat. This is crucial to ensure that the patient can protect their airway and prevent food or fluids from entering the lungs, especially when the throat may be sensitive or compromised post-bronchoscopy. Checking for the wearing off of anesthesia, swallowing reflex, or peristalsis are important assessments but not the immediate priority before feeding in this context.

5. A client with Crohn's disease is receiving parenteral nutrition. Which of the following interventions should the nurse not include in the care of this client?

• A. Remove the parenteral nutrition solution from the refrigerator 2 hours before infusion.
• B. Remove unused parenteral nutrition after 12 hours of use.
• C. Monitor daily laboratory values and report abnormalities as needed.
• D. Monitor the flow rate of the parenteral nutrition carefully and adjust it if necessary.

Correct answer: B

Rationale: In caring for a client receiving parenteral nutrition, it is important to follow proper guidelines to ensure safety and effectiveness. Unused parenteral nutrition should be removed after 24 hours, not 12 hours, to prevent contamination and reduce the risk of infection. Option A is correct as it ensures the solution is at room temperature before infusion. Option C is essential for monitoring the client's response to parenteral nutrition. Option D is important to maintain the correct flow rate and adjust it as needed. Therefore, option B is the incorrect choice among the options provided.

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