Nursing Elites

1. A nurse enters a client's room and sees smoke coming from the trash can. What action should the nurse take first?

• A. Call for assistance
• B. Evacuate the room
• C. Attempt to put out the fire
• D. Turn off the oxygen supply

Correct answer: B

Rationale: In the event of a fire, the priority is to ensure everyone's safety. Therefore, the nurse's initial action should be to evacuate the room. Calling for assistance can be done while evacuating, ensuring help is on the way. Attempting to put out the fire can be dangerous and may delay evacuation. Turning off the oxygen supply is not the first step in this situation, as the immediate concern is to remove individuals from the potential danger.

2. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What instruction should the nurse include?

• A. Reduce sodium intake to 4 grams per day
• B. Avoid foods high in potassium
• C. Take prescribed antihypertensive medications daily
• D. Limit fluid intake to 1 liter per day

Correct answer: C

Rationale: The correct answer is C: 'Take prescribed antihypertensive medications daily.' When providing discharge teaching to a client with hypertension, one of the key instructions is to ensure the consistent intake of prescribed antihypertensive medications. This is crucial for controlling blood pressure levels and reducing the risk of complications associated with hypertension. Choices A, B, and D are incorrect because reducing sodium intake, avoiding foods high in potassium, and limiting fluid intake are important dietary modifications for various health conditions, but they are not the priority when it comes to managing hypertension. The primary focus should be on medication adherence to effectively manage hypertension.

3. A client with diabetes mellitus is being taught about the importance of foot care by a nurse. Which instruction should the nurse include?

• A. Cut toenails straight across
• B. Wear shoes at all times
• C. Soak feet in hot water daily
• D. Apply lotion between the toes

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes at all times.' Clients with diabetes are at a higher risk of foot complications due to poor circulation and nerve damage. Wearing shoes at all times helps protect their feet from injuries. Choice A is incorrect because toenails should be cut straight across to prevent ingrown toenails. Choice C is incorrect as soaking feet in hot water can lead to burns or skin damage, especially for those with diabetes who may have reduced sensation. Choice D is incorrect because applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.

4. A nurse is monitoring a client receiving intermittent enteral feedings. What should the nurse identify as a sign of intolerance to the feeding?

• A. Decreased heart rate
• B. Nausea
• C. Fever
• D. Weight gain

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Nausea can indicate various issues such as feeding intolerance, formula composition problems, or underlying medical conditions. Decreased heart rate, fever, and weight gain are not typical signs of feeding intolerance. Decreased heart rate and fever may indicate other medical conditions, while weight gain is not an immediate sign of intolerance to enteral feedings.

5. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?

• A. Encourage a high-protein diet
• B. Apply a moisture-retentive dressing
• C. Provide daily wound irrigation
• D. Apply an ice pack to the wound

Correct answer: B

Rationale: The correct answer is to apply a moisture-retentive dressing. This promotes a moist wound environment, which is crucial for wound healing in clients with diabetes. Encouraging a high-protein diet may support overall health but is not directly related to wound healing. Daily wound irrigation can disrupt the wound healing process by removing necessary growth factors and cells. Applying an ice pack to the wound is contraindicated as it can impair circulation and delay wound healing.

Similar Questions