Nursing Elites

1. A 78-year-old client with diabetes is being taught how to care for his feet. Which statement by the client indicates a need for further education?

• A. I will soak my feet in warm water every day.
• B. I will use a mirror to check my feet every day.
• C. I will apply lotion to my feet every day, avoiding the area between the toes.
• D. I will wear properly fitting shoes at all times.

Correct answer: A

Rationale: The correct answer is A. Soaking feet daily can lead to excessive moisture, which can increase the risk of skin breakdown or infection in diabetic clients. Choices B, C, and D are all correct statements for foot care in diabetic clients. Using a mirror for daily foot checks helps in early detection of any issues, applying lotion while avoiding the area between the toes helps keep the skin moisturized without creating a risk for fungal infections, and wearing properly fitting shoes is important to prevent pressure points and potential injuries.

2. A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?

• A. Decreased pain and increased redness around the ulcer.
• B. Increased serous drainage from the ulcer site.
• C. Cool extremities and weak peripheral pulses.
• D. Pitting edema around the ulcer site.

Correct answer: C

Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.

3. The healthcare provider is assessing a client who has just received anesthesia. What is the most critical finding to report to the healthcare provider?

• A. Client reports dizziness
• B. Client has a drop in blood pressure
• C. Client experiences mild nausea
• D. Client reports dry mouth

Correct answer: B

Rationale: A significant drop in blood pressure following anesthesia could indicate a serious reaction, such as hypovolemia or anesthetic-induced hypotension. This requires immediate medical attention, while other symptoms like dizziness, mild nausea, and dry mouth are more common and less critical. Dizziness could be expected due to the effects of anesthesia, mild nausea is a common side effect, and dry mouth is a known effect of anesthesia as well.

4. A client with peripheral artery disease reports leg cramps while walking. What intervention should the nurse recommend?

• A. Encourage the client to rest immediately when cramping occurs.
• B. Recommend that the client increase their intake of potassium-rich foods.
• C. Advise the client to take a short break, then continue walking.
• D. Recommend that the client avoid walking altogether to prevent cramps.

Correct answer: C

Rationale: For clients with peripheral artery disease, advising the client to take a short break when leg cramps occur and then continue walking is the appropriate intervention. This approach, known as interval walking, helps manage pain from intermittent claudication and improves circulation over time. Choice A is incorrect because immediate rest may not be necessary, and encouraging the client to resume walking after a short break is more beneficial. Choice B is incorrect since increasing potassium-rich foods may not directly address the underlying issue of peripheral artery disease causing cramps. Choice D is incorrect as avoiding walking altogether can lead to further deconditioning and worsen symptoms over time.

5. A client with a colostomy is being discharged. What teaching is most important for the nurse to provide?

• A. Change the ostomy bag daily to prevent skin irritation.
• B. Avoid foods that can cause gas, such as broccoli.
• C. Empty the ostomy pouch when it is one-third full.
• D. Use a skin barrier to protect the surrounding skin.

Correct answer: C

Rationale: The most important teaching for a client with a colostomy is to empty the ostomy pouch when it is one-third full. This practice helps prevent leakage and skin irritation by maintaining the proper seal of the pouching system. Changing the ostomy bag daily (Choice A) is not necessary unless it leaks or becomes loose. Avoiding gas-producing foods (Choice B) is essential for some clients but is not the most important teaching. Using a skin barrier (Choice D) is important but not as crucial as emptying the ostomy pouch at the right time to prevent complications.

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