Nursing Elites

1. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?

• A. Sensation of taste
• B. Sensation of pressure
• C. Sensation of smell
• D. Urge to defecate

Correct answer: B

Rationale: The correct answer is B: Sensation of pressure. Patients with ileostomy can determine how often their pouch should be drained by feeling the sensation of pressure. This is important as it helps prevent leakage or overflow of the pouch. The sensation of taste (choice A) and smell (choice C) are not typically used as gauges for draining the pouch in ileostomy patients. The urge to defecate (choice D) is not relevant in this context as patients with ileostomy do not pass stool through the rectum.

2. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

• A. Ensure that the bed linen is always dry
• B. Frequently check the bed for wetness and keep it dry
• C. Place a rubber sheet under the client's buttocks
• D. Keep the patient clean and dry

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

3. Poor nutrition results in delayed eruption and exfoliation of deciduous teeth and increased dental caries. Increased caries susceptibility in at-risk children may be related to changes in salivary composition caused by malnutrition.

• A. Both statements are true
• B. Both statements are false
• C. The first statement is true; the second is false
• D. The first statement is false; the second is true

Correct answer: A

Rationale: Both statements are true. Poor nutrition can affect tooth development and increase the risk of dental caries in children.

4. 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.

5. Magnesium's major functions in the body would be least likely to include which of the following?

• A. allowing muscles to relax after contraction
• B. assisting the operation of hundreds of enzymes
• C. synthesis of protein in the soft tissues
• D. regulation of body temperature

Correct answer: D

Rationale: Magnesium plays a key role in muscle relaxation, enzyme operation, and protein synthesis, but it is not directly involved in regulating body temperature.

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