Nursing Elites

1. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take?

• A. Apply zinc oxide ointment to the irritated area
• B. Wipe stool from the skin using store-bought baby wipes
• C. Apply talcum powder to the irritated area
• D. Apply a warm compress to the irritated area

Correct answer: A

Rationale: Correct answer: Applying zinc oxide ointment to the irritated area is the most appropriate action for diaper dermatitis. Zinc oxide is a barrier cream that helps protect the skin and promote healing. Choice B is incorrect because using store-bought baby wipes may contain chemicals or fragrances that can further irritate the skin. Choice C is incorrect as talcum powder can also worsen the condition by drying out the skin. Choice D is incorrect because a warm compress is not typically used for diaper dermatitis; it may provide relief for other conditions but is not the best option for diaper dermatitis.

2. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include?

• A. Massage the affected extremity every 4 hours.
• B. Encourage the client to remain on bed rest.
• C. Apply cold packs to the affected extremity.
• D. Encourage the client to ambulate frequently.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply cold packs to the affected extremity. Cold packs help reduce swelling and pain by causing vasoconstriction. Massaging the affected extremity could dislodge a clot, leading to serious complications. Encouraging bed rest may increase the risk of clot propagation, while frequent ambulation is contraindicated as it can dislodge clots.

3. A client is postoperative following cataract surgery. Which of the following instructions should the nurse include?

• A. Avoid lying flat for 24 hours after surgery.
• B. Avoid bending at the waist.
• C. Wear an eye patch at night for 1 week.
• D. Sleep on your affected side to reduce discomfort.

Correct answer: B

Rationale: The correct instruction that the nurse should include for a client postoperative following cataract surgery is to avoid bending at the waist. Bending at the waist can increase intraocular pressure, which is not recommended after cataract surgery. Choices A, C, and D are incorrect because lying flat for 24 hours after surgery may not be necessary, wearing an eye patch at night for a week is not a standard postoperative instruction for cataract surgery, and sleeping on the affected side may not necessarily reduce discomfort and can increase pressure on the eye.

4. What is the most appropriate method to assess a patient's level of consciousness?

• A. Use the Glasgow Coma Scale
• B. Assess the patient's orientation
• C. Check pupillary response
• D. Monitor vital signs

Correct answer: A

Rationale: The correct answer is A: Using the Glasgow Coma Scale. The Glasgow Coma Scale is a standardized tool used to assess a patient's level of consciousness by evaluating their eye response, verbal response, and motor response. This scale provides a numeric value that helps in determining the severity of brain injury or altered mental status. Choices B, C, and D are incorrect because while assessing the patient's orientation, checking pupillary response, and monitoring vital signs are important components of a comprehensive patient assessment, they do not specifically target the assessment of consciousness level, which is best done using the Glasgow Coma Scale.

5. A nurse is providing teaching to a client who has a new prescription for an albuterol inhaler. Which of the following instructions should the nurse include?

• A. Take one puff every 5 minutes until symptoms improve.
• B. Hold your breath for 10 seconds after inhaling the medication.
• C. Shake the inhaler for 2 seconds before use.
• D. Exhale forcefully after each puff.

Correct answer: B

Rationale: The correct answer is B. Instructing the client to hold their breath for 10 seconds after inhaling the medication allows it to reach deeper into the lungs for maximum effectiveness. Choice A is incorrect because taking one puff every 5 minutes may lead to overuse of the medication. Choice C is incorrect as shaking the inhaler for only 2 seconds may not provide adequate mixing of the medication. Choice D is incorrect because exhaling forcefully after each puff may reduce the amount of medication that reaches the lungs.

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