Nursing Elites

1. A nurse is assessing a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

• A. Heart rate 110/min.
• B. Temperature of 37.4°C (99.3°F).
• C. Respiratory rate of 18/min.
• D. Urine output of 20 mL/hr.

Correct answer: D

Rationale: A urine output of 20 mL/hr is below the expected range and indicates potential renal failure, requiring immediate intervention. In postoperative patients, a urine output less than 30 mL/hr suggests inadequate renal perfusion, a concern that needs prompt attention to prevent renal complications. The heart rate of 110/min, temperature of 37.4°C (99.3°F), and respiratory rate of 18/min are within normal ranges for a postoperative client and do not indicate immediate issues.

2. A nurse is planning care for a client who has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan of care?

• A. Cleanse the wound with povidone-iodine solution daily.
• B. Irrigate the wound with hydrogen peroxide.
• C. Reposition the client every 4 hours.
• D. Use a moisture barrier ointment.

Correct answer: D

Rationale: The correct answer is to use a moisture barrier ointment. This intervention helps protect the skin and promote healing in clients with stage 3 pressure injuries. Cleansing the wound with povidone-iodine solution daily (Choice A) can be too harsh and may delay healing by damaging the surrounding skin. Irrigating the wound with hydrogen peroxide (Choice B) is not recommended as it can be cytotoxic to healing tissue. While repositioning the client every 4 hours (Choice C) is an essential intervention in preventing pressure injuries, it is not directly related to the care of an existing stage 3 pressure injury.

3. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Stay in bed for at least 1 hour if unable to fall asleep.
• B. Take a 1-hour nap during the day.
• C. Perform exercise before bed.
• D. Eat a light snack before bedtime.

Correct answer: D

Rationale: The correct answer is to eat a light snack before bedtime. Consuming a light snack can help promote sleep by preventing discomfort from hunger. Choice A is incorrect because staying in bed for too long when unable to fall asleep can lead to frustration and worsen insomnia. Choice B is incorrect as taking a nap during the day can interfere with nighttime sleep. Choice C is incorrect as exercising before bed can increase alertness and make falling asleep more difficult.

4. A healthcare provider is educating a client with type 2 diabetes mellitus about managing blood glucose levels. Which of the following statements by the client indicates a need for further teaching?

• A. I will monitor my blood glucose levels every morning.
• B. I will stop taking my insulin if my blood glucose level is below 200 mg/dL.
• C. I will take my insulin as prescribed, even if I am feeling well.
• D. I will eat more simple carbohydrates if my blood glucose level is low.

Correct answer: D

Rationale: The correct answer is D because consuming more simple carbohydrates when blood glucose levels are low can cause a rapid spike in blood sugar levels, leading to potential complications. Clients with type 2 diabetes should eat complex carbohydrates or foods that help stabilize blood sugar levels when experiencing hypoglycemia. Choices A, B, and C demonstrate understanding of monitoring blood glucose levels regularly, not stopping insulin without consulting a healthcare provider, and adhering to insulin therapy even when feeling well, which are all appropriate actions for managing diabetes.

5. A nurse is teaching a newly licensed nurse about ergonomic principles. Which action by the newly licensed nurse indicates an understanding of the teaching?

• A. Stand with feet together when lifting a client.
• B. Raise the client's head of bed before pulling the client up.
• C. Use a mechanical lift to move a client.
• D. Place a gait belt around the client's chest before assisting the client.

Correct answer: C

Rationale: The correct answer is C: 'Use a mechanical lift to move a client.' Using a mechanical lift is an essential ergonomic principle to prevent injury and ensure safe client handling. Choice A is incorrect because standing with feet together when lifting a client can lead to instability and improper weight distribution. Choice B is incorrect as raising the client's head of bed before pulling the client up does not primarily relate to ergonomic principles. Choice D is incorrect because while using a gait belt is important for assisting clients with mobility, it is not specifically related to ergonomic principles for safe handling.

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