Nursing Elites

1. 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.

2. A client with a nasogastric tube receiving intermittent enteral feedings should be positioned in which way?

• A. Flush the tube with 15 mL of sterile water before feedings.
• B. Place the client in a supine position during feedings.
• C. Position the client with the head of the bed elevated 45 degrees.
• D. Check gastric residuals every 8 hours.

Correct answer: C

Rationale: Positioning the client with the head of the bed elevated at 45 degrees is crucial during enteral feedings to prevent aspiration. This position helps reduce the risk of regurgitation and aspiration of feedings into the lungs. Option A is not necessary before feedings. Placing the client in a supine position (Option B) increases the risk of aspiration. Checking gastric residuals every 8 hours (Option D) is important but not directly related to positioning during enteral feedings.

3. A nurse is caring for a client who is receiving warfarin therapy. Which of the following laboratory results indicates the need for an increase in the dose of warfarin?

• A. PT 28 seconds
• B. INR 1.2
• C. aPTT 40 seconds
• D. Fibrinogen 350 mg/dL

Correct answer: B

Rationale: An INR of 1.2 is below the therapeutic range for a client on warfarin, indicating inadequate anticoagulation. Therefore, the client would require an increase in the dose of warfarin to achieve the desired therapeutic effect. Choices A, C, and D are not indicative of the need for a dose increase in warfarin therapy. PT of 28 seconds is within the therapeutic range, aPTT of 40 seconds is also within the normal range, and fibrinogen level of 350 mg/dL does not provide information about the anticoagulant effect of warfarin.

4. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?

• A. Diabetes mellitus
• B. Shoulder presentation
• C. Postterm with oligohydramnios
• D. Chorioamnionitis

Correct answer: B

Rationale: Shoulder presentation is a contraindication for oxytocin because it can increase the risk of complications during labor, such as shoulder dystocia. Diabetes mellitus (Choice A) is not a contraindication for the use of oxytocin. Postterm with oligohydramnios (Choice C) and chorioamnionitis (Choice D) may actually necessitate the use of oxytocin to induce or augment labor for the well-being of the mother and baby.

5. A nurse is caring for a client who has experienced a stroke and has aphasia. Which of the following communication strategies should the nurse use?

• A. Speak louder to help the client understand
• B. Speak using simple sentences and gestures
• C. Use a picture board to facilitate communication
• D. Have the client practice writing words down

Correct answer: C

Rationale: The correct answer is to use a picture board to facilitate communication. Aphasia can make it challenging for individuals to understand and use language. Using a picture board can help the client convey their needs and understand information more effectively. Speaking louder (A) may not be helpful as aphasia is not related to hearing loss. While speaking using simple sentences and gestures (B) can be beneficial, using a picture board (C) is a more concrete and visual method to support communication for individuals with aphasia. Having the client practice writing words down (D) may not be suitable if the client's expressive language skills are impaired due to aphasia.

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