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. Where in the body are microvilli located, facilitating the absorption of most nutrients?

• A. Stomach
• B. Pancreas
• C. Large Intestine
• D. Small Intestine

Correct answer: D

Rationale: The correct answer is D: Small Intestine. Microvilli are present in the small intestine, significantly increasing its surface area for efficient absorption of nutrients. The small intestine is the primary site for nutrient absorption in the body. The stomach (choice A) primarily functions to break down food with its acidic environment but is not where most nutrients are absorbed. The pancreas (choice B) produces enzymes to aid in digestion but does not directly absorb nutrients. The large intestine (choice C) mainly absorbs water and electrolytes from undigested food, rather than nutrients.

3. Instruction on health promotion regarding urinary elimination is important. Which would you include?

• A. Hold urine as long as possible before emptying the bladder to strengthen the sphincter muscles
• B. If a burning sensation is experienced while voiding, drink water
• C. After urination, wipe from the anal area towards the pubis
• D. Tell the client to empty the bladder at each voiding

Correct answer: D

Rationale: The correct answer is to instruct the client to empty the bladder at each voiding. This is essential to prevent urinary retention and reduce the risk of urinary tract infections. Choice A is incorrect because holding urine for prolonged periods can lead to urinary retention and increase the risk of infections. Choice B is incorrect as pineapple juice can exacerbate a burning sensation due to its acidity; the correct approach is to drink water to dilute the urine. Choice C is incorrect as wiping from the anal area towards the pubis can introduce bacteria into the urinary tract, potentially causing infections.

4. Which topical antimicrobial is most frequently used in burn wound care?

• A. Neosporin
• B. Silver nitrate
• C. Silver sulfadiazine
• D. Sulfamylon

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.

5. A nurse is caring for a client with a major burn injury and is receiving TPN. Which of the following lab tests is the priority for the nurse to use to confirm the client is receiving adequate nutrition?

• A. Iron
• B. Magnesium
• C. Folic acid
• D. Prealbumin

Correct answer: D

Rationale: Prealbumin is a sensitive indicator of protein status and nutrition, making it a priority for assessing nutritional adequacy in clients receiving TPN. Iron, magnesium, and folic acid levels are important for overall health but do not specifically indicate nutritional adequacy in the context of TPN administration.

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