Nursing Elites

1. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse implement?

• A. Use a donut-shaped cushion for sitting
• B. Turn the client every 4 hours
• C. Elevate the head of the bed to 45 degrees
• D. Massage reddened areas to increase circulation

Correct answer: C

Rationale: Elevating the head of the bed reduces pressure on bony prominences, which helps prevent pressure ulcers.

2. A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?

• A. Social relationships with peers.
• B. Plans for attending school while pregnant.
• C. Eligibility for Medicaid.
• D. Understanding of infant care.

Correct answer: D

Rationale: The correct answer is D: Understanding of infant care. When assessing a pregnant adolescent, the priority is to ensure that she has the necessary knowledge and skills to care for her newborn. This assessment is crucial in promoting the health and well-being of both the adolescent mother and her baby. Option A, social relationships with peers, though important, is not the priority during this assessment. Option B, plans for attending school while pregnant, is also important but does not take precedence over ensuring the adolescent's understanding of infant care. Option C, eligibility for Medicaid, is important for accessing healthcare services but is not the priority assessment in this scenario.

3. A nurse is providing discharge instructions to a client who is postoperative following a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?

• A. I will avoid crossing my legs when sitting.
• B. I will use a raised toilet seat.
• C. I will sleep on my affected side.
• D. I will perform leg exercises every hour while awake.

Correct answer: C

Rationale: The correct answer is C. Sleeping on the affected side could increase the risk of dislocation following a hip arthroplasty. It is essential for the client to avoid sleeping on the surgical side to prevent complications. Choices A, B, and D are correct statements that promote proper postoperative care and reduce the risk of complications. Avoiding crossing legs when sitting, using a raised toilet seat for proper positioning, and performing leg exercises regularly help in the recovery process and prevent complications.

4. A healthcare professional is preparing to administer an IV fluid bolus of 500 mL over 4 hours to a client who is dehydrated. The healthcare professional should set the IV pump to deliver how many mL/hr?

• A. 75 mL/hr.
• B. 100 mL/hr.
• C. 125 mL/hr.
• D. 150 mL/hr.

Correct answer: C

Rationale: Setting the IV pump to 125 mL/hr ensures the correct infusion rate for delivering 500 mL over 4 hours. To calculate the mL/hr rate, divide the total volume to be infused (500 mL) by the total time for infusion (4 hours): 500 mL / 4 hours = 125 mL/hr. Choice A (75 mL/hr) is too low and would result in an insufficient infusion rate, potentially delaying fluid resuscitation. Choice B (100 mL/hr) would also be too low and not deliver the fluid within the specified time frame. Choice D (150 mL/hr) is too high and would infuse the fluid too quickly, potentially causing fluid overload and complications.

5. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?

• A. Encourage the client to take deep breaths.
• B. Administer oxygen as needed.
• C. Teach the client pursed-lip breathing.
• D. Limit the client's fluid intake.

Correct answer: C

Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.

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