Nursing Elites

1. A patient has impaired skin integrity, and a nurse is providing care. What action should the nurse take to promote healing?

• A. Apply a dry, sterile dressing to the wound.
• B. Use sterile saline to clean the wound.
• C. Apply a warm compress to promote circulation.
• D. Keep the wound open to air for faster healing.

Correct answer: B

Rationale: The correct action to promote healing in a patient with impaired skin integrity is to use sterile saline to clean the wound. Sterile saline helps prevent infection and promotes healing of wounds by keeping the area clean. Applying a dry, sterile dressing (Choice A) may not be effective as it does not address the need for wound cleaning. Applying a warm compress (Choice C) may not be suitable for all types of wounds and could potentially cause harm. Keeping the wound open to air (Choice D) is generally not recommended as it can lead to infection and slow down the healing process.

2. What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?

• A. Provide cognitive-behavioral therapy
• B. Offer frequent orientation and reassurance
• C. Administer a sedative to improve memory recall
• D. Refer the client to a neurologist for further evaluation

Correct answer: B

Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.

3. A patient recovering from a stroke has difficulty swallowing. Which action should the nurse prioritize?

• A. Begin feeding the patient soft solids.
• B. Place the patient on NPO (nothing by mouth) status.
• C. Provide ice chips to help soothe the throat.
• D. Start the patient on a clear liquid diet.

Correct answer: B

Rationale: The correct answer is to place the patient on NPO (nothing by mouth) status. Patients recovering from a stroke with difficulty swallowing are at high risk for aspiration, which can lead to serious complications like aspiration pneumonia. Therefore, the priority is to keep the patient on NPO until a thorough evaluation by a healthcare provider is completed. Choice A is incorrect as feeding the patient soft solids can increase the risk of aspiration. Choice C is incorrect as providing ice chips may further compromise swallowing safety. Choice D is incorrect as starting the patient on a clear liquid diet can also increase the risk of aspiration in this scenario.

4. A nurse in a clinic is caring for a client who has a urinary tract infection (UTI). Which of the following prescriptions should the nurse verify with a provider?

• A. Trimethoprim-sulfamethoxazole
• B. Hyoscyamine
• C. Oxybutynin
• D. Phenazopyridine

Correct answer: C

Rationale: The correct answer is C, Oxybutynin. Oxybutynin can worsen urinary retention, so the nurse should verify this prescription with the provider. Trimethoprim-sulfamethoxazole (Choice A) is a common antibiotic used to treat UTIs and does not require verification. Hyoscyamine (Choice B) is an anticholinergic medication used for bladder spasms and does not typically worsen UTI symptoms. Phenazopyridine (Choice D) is a urinary analgesic that helps relieve pain, burning, and discomfort caused by a UTI, which may not necessarily require verification in this scenario.

5. Which intervention is most effective in preventing deep vein thrombosis (DVT) in a postoperative patient?

• A. Encourage the patient to drink plenty of fluids.
• B. Encourage early ambulation and leg exercises.
• C. Administer anticoagulants as prescribed.
• D. Apply compression stockings to the patient's legs.

Correct answer: B

Rationale: The most effective intervention in preventing deep vein thrombosis (DVT) in a postoperative patient is to encourage early ambulation and leg exercises. Early ambulation helps promote circulation, preventing stasis and reducing the risk of blood clot formation. Encouraging the patient to drink plenty of fluids (choice A) is important for overall health but is not the most effective intervention for preventing DVT. Administering anticoagulants (choice C) is a valuable intervention in some cases, but it may not be suitable for all postoperative patients. Applying compression stockings (choice D) can help prevent DVT but is generally not as effective as early ambulation and leg exercises in postoperative patients.

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