Nursing Elites

1. A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Use a special mattress for the client
• C. Keep the client on bedrest
• D. Encourage the client to remain in one position

Correct answer: B

Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.

2. A client with a new diagnosis of hypertension is receiving discharge teaching. What should the nurse emphasize regarding lifestyle changes?

• A. Limit sodium intake to 2 grams per day
• B. Increase fluid intake to 2 liters per day
• C. Avoid potassium-rich foods
• D. Avoid alcohol consumption

Correct answer: B

Rationale: The correct answer is to increase fluid intake to 2 liters per day. Adequate fluid intake helps manage hypertension and prevent fluid retention. Limiting sodium intake, avoiding potassium-rich foods, and abstaining from alcohol are important aspects of managing hypertension; however, in this scenario, emphasizing the increase in fluid intake is crucial for the client's understanding and compliance.

3. 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.

4. A nurse is planning to administer multiple medications to a client with dysphagia. What action should the nurse take?

• A. Crush medications and mix them with honey
• B. Provide medications through a straw
• C. Place the medications in small amounts of pudding
• D. Offer the medications with a full glass of water

Correct answer: C

Rationale: The correct action for the nurse to take when administering medications to a client with dysphagia is to place the medications in small amounts of pudding. Mixing medications with pudding helps clients with dysphagia swallow them more easily. Choice A (crushing medications and mixing with honey) is not recommended as it may alter the medication properties. Choice B (providing medications through a straw) is not suitable for clients with dysphagia as it can pose a choking hazard. Choice D (offering medications with a full glass of water) may be difficult for clients with dysphagia to swallow and increase the risk of aspiration.

5. A nurse is assessing a client who reports pain and redness at the site of a peripheral IV. What should the nurse do first?

• A. Apply a cold compress to the site
• B. Discontinue the IV line
• C. Notify the provider
• D. Increase the IV flow rate

Correct answer: B

Rationale: When a client reports pain and redness at the site of a peripheral IV, indicating signs of phlebitis, the nurse's initial action should be to discontinue the IV line. This helps prevent further complications and ensures patient safety. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider (Choice C) is important but not the initial step. Increasing the IV flow rate (Choice D) can exacerbate the inflammation and should be avoided.

Similar Questions