Nursing Elites

1. A nurse is caring for a client who is 24 hours postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?

• A. Does the doctor know you are eating that?
• B. Why are you eating seaweed soup?
• C. Of course, I will heat that up for you.
• D. The hospital food is more nutritious.

Correct answer: C

Rationale: Respecting cultural preferences promotes trust and client-centered care.

2. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?

• A. Monitor the client's IV site for thrombophlebitis
• B. Administer flumazenil to the client
• C. Evaluate the client for further suicidal behavior
• D. Initiate seizure precautions for the client

Correct answer: B

Rationale: In cases of benzodiazepine overdose, such as diazepam ingestion, flumazenil is the antidote. Therefore, the priority action for the nurse is to administer flumazenil to the client. Monitoring the IV site for thrombophlebitis (Choice A) is important but not the immediate priority. Evaluating the client for further suicidal behavior (Choice C) is important but not the next immediate action. Initiating seizure precautions (Choice D) is not the priority as the client's airway has already been secured.

3. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 92%
• B. Use of pursed-lip breathing
• C. Increased anterior-posterior chest diameter
• D. Productive cough with green sputum

Correct answer: D

Rationale: The correct answer is D. A productive cough with green sputum can indicate a bacterial infection, which is a concern for clients with COPD. Reporting this finding to the provider is important for further evaluation and management. Choices A, B, and C are not as concerning in the context of COPD management. An oxygen saturation of 92% is within an acceptable range for COPD patients, pursed-lip breathing is a helpful technique for managing breathing difficulties in COPD, and an increased anterior-posterior chest diameter is a common finding in clients with COPD due to chronic air trapping.

4. A client with a new diagnosis of diabetes mellitus is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water every day to prevent dryness.
• B. Trim your toenails straight across to prevent injury.
• C. Apply lotion between your toes after bathing.
• D. Wear cotton socks to keep your feet dry.

Correct answer: B

Rationale: The correct answer is B: 'Trim your toenails straight across to prevent injury.' In clients with diabetes, trimming toenails straight across is essential to prevent ingrown toenails and injury. Choice A is incorrect because soaking feet in warm water can lead to dryness, which is not recommended for diabetic foot care. Choice C is incorrect as applying lotion between the toes can create excess moisture, increasing the risk of fungal infections. Choice D is incorrect because although cotton socks are recommended, the primary purpose is to prevent moisture buildup, not specifically to keep the feet dry.

5. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges.
• B. Don sterile gloves.
• C. Normal saline
• D. Determine pain level.

Correct answer: D

Rationale: The correct answer is to determine the pain level first. Assessing the client's pain is crucial before any procedure to ensure their comfort and safety. Applying skin preparation to wound edges (Choice A) may come later in the process after ensuring the client's comfort. Donning sterile gloves (Choice B) is important before directly handling the wound but can follow pain assessment. Normal saline (Choice C) might be used during wound cleansing but is not the initial step in this situation.

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