Nursing Elites

1. When assisting a client with bilateral casts on her hands with feeding, what action should the nurse take?

• A. Sit at the bedside when feeding the client
• B. Provide pureed foods
• C. Ensure feedings are provided at room temperature
• D. Offer the client a drink of fluid after every bite

Correct answer: A

Rationale: When assisting a client with bilateral casts on her hands with feeding, the nurse should sit at the bedside. This action is crucial to provide the client with the nurse's full attention during the feeding process. Sitting at the bedside helps avoid appearing rushed and ensures a safe and comfortable environment for the client. Choices B, C, and D are incorrect because while they may be relevant in other situations, the priority when assisting a client with bilateral casts on her hands is to ensure proper attention and a comfortable setting during feeding.

2. A client has a tracheostomy and requires suctioning. Which of the following actions should be taken?

• A. Hyperoxygenate the client before suctioning
• B. Insert the catheter while exhalation
• C. Apply suction after inserting the catheter
• D. Limit suctioning to no more than 15 seconds

Correct answer: A

Rationale: Hyperoxygenating the client before suctioning is crucial to prevent hypoxia during the procedure. By using a manual resuscitation bag with 100% oxygen, the nurse should provide several breaths to the client to ensure sufficient oxygenation before starting suctioning. This approach helps maintain oxygen levels and decreases the risk of hypoxia, which may arise when suctioning interrupts the normal respiratory process. Choices B, C, and D are incorrect because inserting the catheter during exhalation, applying suction while inserting the catheter, and limiting suctioning to 15 seconds do not address the priority of hyperoxygenating the client to prevent hypoxia.

3. A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following interventions should the healthcare provider include?

• A. Massage the ulcer
• B. Apply a heating pad
• C. Reposition the client every 2 hours
• D. Use alcohol-based cleansers

Correct answer: C

Rationale: Repositioning the client every 2 hours is a crucial intervention in the management of pressure ulcers. This action helps redistribute pressure, reducing the risk of further skin breakdown and promoting wound healing. Massaging the ulcer can cause further damage to the skin and underlying tissues. Applying a heating pad can increase the risk of skin breakdown and should be avoided. Alcohol-based cleansers are too harsh for pressure ulcers and can irritate the skin, potentially delaying healing.

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

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

Correct answer: B

Rationale: Correct! Hyperkalemia is a condition characterized by high levels of potassium in the blood. To manage hyperkalemia, it is essential to decrease the intake of potassium-rich foods since excess potassium can worsen the condition. By understanding the need to decrease potassium-rich foods, the client shows comprehension of the dietary management required for hyperkalemia. Choice A is incorrect because increasing potassium-rich foods would exacerbate hyperkalemia. Choice C is incorrect since increasing sodium-rich foods is unrelated to managing hyperkalemia and could potentially lead to other health issues. Choice D is incorrect as decreasing sodium-rich foods is not the primary focus when managing hyperkalemia.

5. When administering an IM injection to a 5-month-old infant, which of the following injection sites should be used?

• A. Deltoid
• B. Ventrogluteal
• C. Vastus lateralis
• D. Dorsogluteal

Correct answer: C

Rationale: For infants and young children, the vastus lateralis muscle located over the anterior thigh is the preferred site for intramuscular injections. This site is chosen for its large muscle mass and reduced risk of injury to major nerves and blood vessels. Infants have less developed muscle structures, making the vastus lateralis a safer and more effective site for injections compared to other sites like the deltoid, ventrogluteal, or dorsogluteal. Using the correct injection site is essential to prevent complications and ensure the proper absorption of the medication.

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