Nursing Elites

1. A client has urinary incontinence, and the nurse is caring for them. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

• A. Request a prescription for the insertion of an indwelling urinary catheter
• B. Check the client's skin every 8 hours for signs of breakdown
• C. Apply a moisture barrier ointment to the client's skin
• D. Clean the client's skin and perineum with hot water after each episode of incontinence

Correct answer: C

Rationale: The correct action to prevent skin breakdown in a client with urinary incontinence is to apply a moisture barrier ointment to the skin. This ointment helps protect the skin from the harmful effects of moisture exposure, reducing the risk of breakdown. Requesting an indwelling urinary catheter (Choice A) should not be the first-line intervention for skin breakdown prevention. Checking the client's skin for signs of breakdown (Choice B) is important but not as effective as applying a moisture barrier. Cleaning the skin with hot water (Choice D) can actually be detrimental as hot water can strip the skin of its natural oils and worsen skin integrity.

2. The nurse is performing hand hygiene before assisting a healthcare provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next?

• A. Repeat handwashing using antiseptic soap.
• B. Inform the healthcare provider and recruit another nurse to assist.
• C. Extend the handwashing procedure to 5 minutes.
• D. Rinse and dry hands and begin assisting the healthcare provider.

Correct answer: A

Rationale: The correct answer is A. The sink is considered a contaminated area. When hand hygiene is compromised during the process, it is essential to repeat handwashing using antiseptic soap to ensure proper hygiene. Choice B is incorrect because the situation can be managed by proper handwashing. Choice C is incorrect as extending the handwashing procedure to 5 minutes is not necessary in this scenario. Choice D is incorrect as the hands need to be properly cleaned before assisting the healthcare provider.

3. A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?

• A. Gelatin
• B. Broth
• C. Popsicle
• D. Yogurt

Correct answer: D

Rationale: The correct answer is D, Yogurt. Yogurt is not part of a clear liquid diet. A clear liquid diet includes transparent or translucent liquids such as gelatin, broth, and popsicles. Yogurt is a thicker consistency and contains solid particles, making it inappropriate for a clear liquid diet. Choices A, B, and C are suitable options for a client following a clear liquid diet.

4. A healthcare provider gives a verbal order for a medication. The nurse is uncomfortable with the order and questions its appropriateness. What should the nurse do?

• A. Refuse to administer the medication and document the refusal.
• B. Clarify the order with the provider before proceeding.
• C. Administer the medication and monitor the patient.
• D. Call a pharmacy consult to discuss the medication.

Correct answer: B

Rationale: The correct action for the nurse to take when uncomfortable with a verbal order for medication is to clarify the order with the provider before proceeding. This ensures patient safety by confirming the appropriateness of the order and prevents any potential harm. Choice A is incorrect because refusing to administer the medication without clarification may delay necessary treatment for the patient. Choice C is incorrect as administering the medication without clarification could pose risks if the order is indeed inappropriate. Choice D is also incorrect as the first step should be direct clarification with the provider before involving others.

5. A nurse is teaching a client who has a new prescription for amoxicillin clavulanate to treat pharyngitis. Which statement indicates understanding?

• A. I will double my dose if I miss one
• B. I should take this medication on an empty stomach between meals
• C. I will take the medication until my sore throat goes away
• D. I will stop taking this medication if I develop itching

Correct answer: C

Rationale: The client should never double the dose if a dose is missed. This can lead to an overdose, which can cause serious adverse effects. Instead, the client should take the next dose as scheduled or consult the provider for guidance.

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