Nursing Elites

1. When caring for a client with a prescription for wound irrigation, which action should the nurse take?

• A. Use a 10-mL syringe with an 18-gauge needle.
• B. Cleanse the wound from the center outward.
• C. Apply a wet-to-dry dressing.
• D. Pack the wound tightly with gauze.

Correct answer: B

Rationale: When caring for a client with a prescription for wound irrigation, the nurse should cleanse the wound from the center outward. This technique helps prevent the introduction of microorganisms into the wound, reducing the risk of contamination and promoting effective wound healing. By using a circular motion from the cleanest area to the least clean areas, debris and bacteria are moved away from the wound site, decreasing the chances of infection.

2. A client with a new diagnosis of diverticulitis is being taught dietary management by a healthcare provider. Which of the following statements should the provider include in the teaching?

• A. You should increase your intake of high-fiber foods.
• B. You should avoid foods that contain lactose.
• C. You should decrease your intake of high-fiber foods.
• D. You should increase your intake of dairy products.

Correct answer: A

Rationale: Increasing intake of high-fiber foods is essential in managing diverticulitis as it promotes regular bowel movements and prevents constipation, reducing the risk of complications and improving overall digestive health. Choice B is incorrect because lactose intolerance is different from diverticulitis and avoiding lactose is not a standard recommendation for diverticulitis. Choice C is incorrect as decreasing high-fiber foods would be counterproductive for managing diverticulitis. Choice D is wrong because increasing dairy products is not a primary dietary recommendation for diverticulitis management.

3. A client has a stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?

• A. Apply a heat lamp to the area for 20 minutes each day.
• B. Change the dressing on the heel every 12 hours.
• C. Apply a transparent dressing over the heel.
• D. Use a water pressure mattress.

Correct answer: C

Rationale: Applying a transparent dressing over the heel is beneficial as it can protect the ulcer from friction and shear, and allow for continuous observation of the wound. This intervention promotes healing and prevents further damage to the skin. Choice A is incorrect because applying heat can increase the risk of tissue damage and should be avoided. Choice B is incorrect as changing the dressing every 12 hours may disrupt the wound healing process and is not necessary for a stage 1 pressure ulcer. Choice D is incorrect because using a water pressure mattress is not a specific intervention for a stage 1 pressure ulcer on the heel.

4. A client with hypothyroidism is being taught about dietary management. Which statement by the client indicates an understanding of the teaching?

• A. I should increase my intake of iodine-rich foods.
• B. I should decrease my intake of iodine-rich foods.
• C. I should increase my intake of potassium-rich foods.
• D. I should decrease my intake of sodium-rich foods.

Correct answer: A

Rationale: The correct answer is A. Increasing intake of iodine-rich foods is beneficial for clients with hypothyroidism as iodine is essential for thyroid hormone synthesis. Adequate iodine intake helps to support thyroid function in individuals with hypothyroidism, making choice A the most appropriate response indicating an understanding of the dietary management for this condition. Choices B, C, and D are incorrect because decreasing iodine-rich foods, increasing potassium-rich foods, or decreasing sodium-rich foods are not the recommended dietary modifications for hypothyroidism. In fact, decreasing iodine-rich foods could exacerbate hypothyroidism due to the essential role of iodine in thyroid hormone production.

5. A healthcare provider is preparing to administer an intramuscular injection to an adult client. Which of the following injection sites should the healthcare provider select?

• A. Deltoid muscle
• B. Dorsogluteal muscle
• C. Vastus lateralis muscle
• D. Rectus femoris muscle

Correct answer: A

Rationale: The deltoid muscle is a common site for intramuscular injections in adults due to its accessibility and muscle mass. It is located in the upper arm and provides a sufficient area for injection. The deltoid muscle is preferred for administering vaccines and other medications that require IM administration. Choice B, the dorsogluteal muscle, is not recommended for intramuscular injections due to the proximity of major nerves and blood vessels in that area, which can lead to nerve damage or injury. Choice C, the vastus lateralis muscle, is more commonly used for infants and young children, while choice D, the rectus femoris muscle, is not typically used for intramuscular injections in adults.

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