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. The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” as important in documenting in which of the following areas of mental status examination?

• A. Thought content
• B. Mood
• C. Affect
• D. Attitude

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.

3. While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:

• A. Set and turn on the alarm of the oximeter
• B. Do nothing since there is no identified problem
• C. Cover the fingertip sensor with a towel or bedsheet
• D. Change the location of the sensor every four hours

Correct answer: B

Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.

4. What is the movement of water from an area of lower solute concentration to one of higher solute concentration called?

• A. Hypodipsia
• B. Hypernatremia
• C. Hypokalemia
• D. Osmosis

Correct answer: D

Rationale: The correct answer is D, Osmosis. Osmosis is the process where water moves from an area of low solute concentration to an area of high solute concentration. This movement equalizes the solute concentration in intracellular and extracellular fluids. Choices A, B, and C are incorrect because they do not describe the movement of water based on solute concentration levels.

5. What is the role of fat in digestion?

• A. Digest fats in the stomach
• B. Emulsify fats in the small intestine
• C. Transport fats through the circulatory system
• D. Split fats into smaller components

Correct answer: B

Rationale: The correct answer is B: Emulsify fats in the small intestine. Bile emulsifies fats in the small intestine, breaking them down into smaller droplets that can be more easily digested by enzymes like lipase. Choice A is incorrect as fats are not digested in the stomach but rather in the small intestine. Choice C is incorrect as fats are transported through the lymphatic system instead of the circulatory system. Choice D is incorrect as fats are broken down into smaller components through emulsification, not splitting.

Similar Questions