Nursing Elites

1. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if pt:

• A. Lubricates the tip of the catheter prior to inserting into the stoma
• B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
• C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
• D. Clamps of the flow of fluid when felling uncomfortable

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

2. Each of the following is a function of vitamin A, except one. Which is the exception?

• A. Prevention of night blindness
• B. Growth of soft tissues and bone
• C. Maintenance of more than 200 genes
• D. Integrity of body openings and their linings

Correct answer: C

Rationale: The correct answer is C. Maintenance of more than 200 genes is not a function of vitamin A; instead, it is a function of Vitamin D. Vitamin A plays a crucial role in the prevention of night blindness by aiding in the production of the visual pigment rhodopsin. It also supports the growth of soft tissues and bone, as well as the integrity of body openings and their linings. Choice C is incorrect because the maintenance of genes is primarily associated with Vitamin D, not Vitamin A.

3. A patient on a low-sodium diet should avoid which of the following foods?

• A. Fresh fruits
• B. Unsalted nuts
• C. Canned soup
• D. Plain rice

Correct answer: C

Rationale: Canned soup is the correct answer. Canned soups are often high in sodium due to added salt and should be avoided on a low-sodium diet. Fresh fruits (Choice A) are typically low in sodium and a good choice for a low-sodium diet. Unsalted nuts (Choice B) are also low in sodium and can be included in a low-sodium diet. Plain rice (Choice D) is a low-sodium food and can be part of a low-sodium diet.

4. What is the primary function of a written nursing care plan?

• A. Evaluates whether nursing care goals have been achieved
• B. Ensures the provision of quality nursing care
• C. Assists in selecting the appropriate nursing interventions
• D. Facilitates the creation of a nursing diagnosis

Correct answer: D

Rationale: A written nursing care plan fundamentally serves to facilitate the development of a nursing diagnosis. This procedure involves analyzing patient data and identifying health problems that nurses can address independently. This analysis then aids in determining the most appropriate nursing interventions for the identified health issues. Although evaluating the achievement of nursing care goals is an important aspect, it is not the primary function of a nursing care plan. Similarly, while delivering quality nursing care is crucial, it is a broader concept that includes many other facets beyond just the initial nursing diagnosis and interventions.

5. A client receiving continuous enteral tube feeding reports cramping and abdominal distention. Which of the following actions should the nurse take?

• A. Check for gastric residual.
• B. Apply low intermittent suction.
• C. Increase the rate of the feeding.
• D. Request a higher-fat formula.

Correct answer: A

Rationale: When a client on continuous enteral tube feeding experiences cramping and abdominal distention, the nurse should check for gastric residual. This assessment helps determine if the client is tolerating the feeding well or if there is a potential issue such as feeding intolerance. Applying low intermittent suction, increasing the feeding rate, or requesting a higher-fat formula are not appropriate actions for addressing the reported symptoms and may exacerbate the client's discomfort or lead to further complications.

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