Nursing Elites

1. When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma?

• A. Antiseptic cream
• B. Petroleum jelly
• C. Cornstarch
• D. Stomadhesive

Correct answer: D

Rationale: The correct answer is 'Stomadhesive.' Stomadhesive is a protective barrier used around the stoma to prevent skin irritation and to secure the colostomy bag. This preparation helps to maintain skin integrity and prevent complications such as skin breakdown. Antiseptic cream (Choice A) is not typically used around the stoma as it can irritate the skin. Petroleum jelly (Choice B) is also not recommended as it can interfere with the adhesive properties of the colostomy appliance. Cornstarch (Choice C) is not suitable for application around the stoma as it can promote moisture and lead to skin irritation.

2. The nurse is caring for a client with pericarditis. Which of the following nursing interventions will promote comfort for the client?

• A. Auscultating the client's heart sounds
• B. Provide the client with a diversionary activity
• C. Encourage deep breathing
• D. Maintain a patent intravenous access

Correct answer: B

Rationale: Providing a diversionary activity is the most appropriate nursing intervention to promote comfort for a client with pericarditis. This intervention helps to distract the patient and reduce discomfort by focusing their attention elsewhere. Auscultating heart sounds, while important for monitoring the condition, does not directly address the client's comfort. Encouraging deep breathing can be beneficial for some conditions but may not be specifically aimed at promoting comfort in pericarditis. Maintaining a patent intravenous access is essential for treatment access and management of the condition, but it does not directly promote comfort for the client.

3. Which assessment finding would most likely indicate a complication of enteral tube feeding?

• A. Abdominal distension
• B. Weight gain
• C. Decreased bowel sounds
• D. Diarrhea

Correct answer: A

Rationale: Abdominal distension in a patient receiving enteral tube feeding may indicate a complication such as intolerance to feeding, delayed gastric emptying, or obstruction. Abdominal distension is a common sign of gastrointestinal issues related to enteral tube feeding. Weight gain is typically an expected outcome if the patient is receiving adequate nutrition. Decreased bowel sounds may indicate decreased motility but are not specific to enteral tube feeding complications. Diarrhea can occur due to various reasons, including infections, medications, or dietary changes, but it is not the most likely indication of a complication in enteral tube feeding.

4. After a laparoscopic cholecystectomy, what is the most important instruction the nurse should give the client regarding post-operative care at home?

• A. Avoid lifting heavy objects for at least a week.
• B. Follow a low-fat diet.
• C. Monitor the incision sites for signs of infection.
• D. Resume normal activities as tolerated.

Correct answer: C

Rationale: Monitoring the incision sites for signs of infection is crucial after a laparoscopic cholecystectomy. Infections can lead to serious complications if not detected early. While avoiding heavy lifting and following a low-fat diet are important aspects of recovery, monitoring for infection takes precedence as it directly impacts the client's immediate post-operative well-being. Therefore, option C is the correct answer as it addresses the most critical aspect of post-operative care.

5. The PN notes that a UAP is ambulating a male client who had a stroke and has right-sided weakness. The UAP is walking on the client's left side. Which action should the PN take?

• A. Instruct the UAP to walk on the client's affected side
• B. Take over the ambulation and provide guidance to the UAP immediately
• C. Provide the client with an assistive device, such as a cane or walker
• D. Tell the UAP to take the client back to his room

Correct answer: A

Rationale: The correct action for the PN to take is to instruct the UAP to walk on the client’s affected side. This is essential to provide the necessary support and prevent falls, especially when the client has weakness on one side due to a stroke. Walking on the affected side helps provide stability and assistance to the weaker side. Choice B is incorrect because it would be more appropriate for the PN to provide immediate guidance and correct the UAP's positioning rather than taking over the task completely. Choice C is incorrect because while assistive devices may be beneficial, the immediate concern is the UAP's positioning during ambulation, not providing the client with an assistive device. Choice D is incorrect as there is no indication to return the client to his room unless it is necessary for his safety or well-being.

Similar Questions