Nursing Elites

1. A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. Which term should the nurse use to document this finding?

• A. Papule
• B. Macule
• C. Nodule
• D. Tumor

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion is less than 0.5cm, fitting the description of a macule. A papule (choice A) is a solid, elevated lesion less than 0.5 cm in diameter. A nodule (choice C) is a solid, elevated lesion that is 0.5 cm or larger in diameter. A tumor (choice D) refers to a mass of abnormal tissue growth, which is not applicable in this scenario.

2. A client with an indwelling urinary catheter is being cared for by a nurse. What finding indicates a catheter occlusion?

• A. Bladder distention
• B. Frequent urination
• C. Hematuria
• D. Burning sensation

Correct answer: A

Rationale: Bladder distention is the correct answer as it indicates that the catheter is not draining properly, which is a sign of occlusion. Frequent urination, hematuria, and burning sensation are not indicative of a catheter occlusion. Frequent urination may suggest a bladder that is not fully emptying, hematuria indicates blood in the urine, and a burning sensation can be a sign of a urinary tract infection, none of which directly relate to a catheter occlusion.

3. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What is the nurse's priority action?

• A. Flush the IV line with saline
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion. The symptoms described - pain, redness, and warmth along the vein - are indicative of phlebitis, which is inflammation of the vein. Continuing the infusion can lead to further complications. Flushing the IV line, elevating the limb, or applying a cold compress do not address the underlying issue of phlebitis and may not be sufficient to resolve the problem. Therefore, the priority action is to discontinue the infusion to prevent worsening of the condition.

4. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. What should the nurse do to prevent contamination?

• A. Wear non-sterile gloves
• B. Apply sterile gloves over non-sterile gloves
• C. Change gloves if the sterile solution splashes onto the sterile field
• D. Cover the sterile field with a sterile drape

Correct answer: C

Rationale: The correct answer is C. If sterile solution splashes onto the sterile field, it is considered contaminated. Changing gloves in this situation ensures that the sterility of the dressing change is maintained. Choice A is incorrect as non-sterile gloves would introduce contaminants. Choice B is incorrect as layering gloves can increase the risk of contamination. Choice D is incorrect as covering the sterile field with a sterile drape is not the appropriate action to take in response to contamination.

5. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Apply a moisture-retentive dressing
• C. Apply a heating pad to the site
• D. Keep the client on bedrest

Correct answer: B

Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.

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