Nursing Elites

1. While documenting client care, which entry should the nurse identify as an example of implementing client care?

• A. Documenting the client's pain level
• B. Monitoring the client's urine output
• C. Assessing the client's range of motion
• D. Contacting the provider to report client findings

Correct answer: D

Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.

2. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?

• A. Apply a heating pad to the wound
• B. Apply a moisture-retentive dressing
• C. Provide daily wound irrigation
• D. Apply an ice pack to the wound

Correct answer: B

Rationale: The correct answer is to apply a moisture-retentive dressing. This type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.

3. A client scheduled for cataract surgery tells the nurse, 'I see just fine and have decided to cancel my surgery.' What should the nurse do?

• A. Proceed with the surgery as planned
• B. Document the refusal and inform the surgeon
• C. Explain the benefits of the surgery
• D. Respect the client's decision

Correct answer: C

Rationale: In this scenario, the nurse should explain the benefits of the surgery to the client. By providing more information, the client may reconsider their decision after understanding the positive impact the surgery could have on their vision. Proceeding with the surgery against the client's wishes (Choice A) is not ethical and goes against the principle of autonomy. While documenting the refusal and informing the surgeon (Choice B) is important for the client's medical record, it is crucial to first try to educate the client about the benefits. Simply respecting the client's decision (Choice D) without attempting to provide more information may not be in the client's best interest.

4. A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and warm. What should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the IV line
• C. Apply a cold compress
• D. Elevate the limb

Correct answer: B

Rationale: When a client presents with symptoms of phlebitis at the IV site, such as redness, warmth, and pain, it is essential to discontinue the IV line. Increasing the IV flow rate could exacerbate the condition by further irritating the vein. Applying a cold compress may provide temporary relief but does not address the underlying issue of phlebitis. Elevating the limb is not the primary intervention for phlebitis and discontinuing the IV line takes precedence to prevent complications.

5. A healthcare professional is reviewing the health history of a client who has a hip fracture. What is a risk factor for developing pressure injuries?

• A. Increased fluid intake
• B. Urinary incontinence
• C. Poor nutrition
• D. Immobility

Correct answer: B

Rationale: Urinary incontinence is a risk factor for developing pressure injuries as it can lead to skin breakdown due to constant exposure to moisture and irritation. Increased fluid intake is important for hydration and overall health but is not directly linked to pressure injuries. Poor nutrition can impair wound healing but is not a direct risk factor for pressure injuries. Immobility can contribute to the development of pressure injuries but is not as directly related as urinary incontinence.

Similar Questions