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. An adolescent client has bloodshot eyes, a voracious appetite, and dry mouth. Which drug abuse would the nurse most likely suspect?

• A. Marijuana
• B. Amphetamines
• C. Barbiturates
• D. Anxiolytics

Correct answer: A

Rationale: The symptoms described, including bloodshot eyes, a voracious appetite, and dry mouth, are consistent with marijuana use. Bloodshot eyes are a common side effect of marijuana due to its effect on blood vessels in the eyes. Marijuana also often causes an increase in appetite (known as 'the munchies') and can result in dry mouth. Amphetamines typically cause symptoms like increased alertness, energy, and decreased appetite. Barbiturates and anxiolytics would not typically cause bloodshot eyes, a voracious appetite, and dry mouth as described in the scenario. Therefore, the most likely drug abuse the nurse would suspect in this case is marijuana.

3. Mr. CKK is unconscious and was brought to the E.R. Who among the following can give consent for CKK's operation?

• A. Doctor
• B. Nurse
• C. Next of Kin
• D. The Patient

Correct answer: A

Rationale: In the scenario described, when a patient is unconscious and unable to provide consent, the responsibility usually falls on the physician to make decisions regarding the patient's treatment, including obtaining consent for an operation. While nurses play a crucial role in patient care, they typically do not have the authority to provide consent for a major procedure. The next of kin may be consulted for input, but the ultimate decision-making authority lies with the physician. The patient, being unconscious, is unable to provide consent in this situation.

4. A nurse is instructing teenage girls on the importance of adequate calcium intake throughout their life span to prevent complications. Which complication should the nurse include in the teaching?

• A. Goiter
• B. Osteoporosis
• C. Heart disease
• D. Dental caries

Correct answer: B

Rationale: The correct answer is B: Osteoporosis. Adequate calcium intake throughout life helps prevent osteoporosis, a condition characterized by weak and brittle bones, which is common in older adults. Goiter is caused by an iodine deficiency, not calcium. Heart disease is more related to factors like cholesterol and blood pressure. Dental caries are primarily influenced by oral hygiene and sugar intake, not just calcium.

5. A nurse is providing nutritional information to a client with osteoporosis. Which food should the nurse recommend as being the highest in calcium?

• A. 1 cup carrot strips
• B. 3 oz canned salmon
• C. 1 plain baked potato
• D. 1 cup chopped chicken breast

Correct answer: B

Rationale: Canned salmon with bones is high in calcium.

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