Nursing Elites

1. A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following actions should the healthcare provider take?

• A. Massage the reddened area.
• B. Apply a heating pad to the area.
• C. Elevate the head of the bed to 45 degrees.
• D. Reposition the client every 2 hours.

Correct answer: D

Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers from worsening. This action helps relieve pressure on specific areas, improving circulation and reducing the risk of tissue damage. Massaging the reddened area can further damage the skin, applying heat can increase the risk of skin breakdown, and elevating the head of the bed to 45 degrees may not directly address the pressure ulcer prevention. Proper positioning is essential to avoid prolonged pressure on the affected areas and promote healing.

2. A client with dysphagia and at risk for aspiration needs care planning. Which intervention should the nurse include in the plan?

• A. Encourage the client to drink thickened liquids.
• B. Instruct the client to swallow with chin tucked.
• C. Provide the client with a cup with a lid.
• D. Place the client in Fowler's position for meals.

Correct answer: D

Rationale: Placing the client in Fowler's position is crucial in preventing aspiration as it helps maintain an open airway and reduces the risk of food or liquid entering the lungs during swallowing. This position promotes safer swallowing and minimizes the chances of aspiration pneumonia. Choices A, B, and C are less effective interventions for preventing aspiration. Encouraging the client to drink thickened liquids may help, but the position is more critical. Instructing the client to swallow with chin tucked is beneficial for some individuals but not as effective as positioning. Providing a cup with a lid does not directly address the risk of aspiration associated with dysphagia.

3. A client has a new prescription for digoxin, and a nurse is providing teaching. Which of the following client statements indicates an understanding of the teaching?

• A. I will take my pulse before taking this medication.
• B. I will take this medication with an antacid.
• C. I will double the dose if I miss one.
• D. I will avoid eating bananas.

Correct answer: A

Rationale: The correct answer is A because taking the pulse before administering digoxin is crucial as the medication can cause bradycardia. Monitoring the pulse helps in identifying any signs of bradycardia, a common side effect of digoxin. Options B, C, and D are incorrect. Taking digoxin with an antacid may interfere with its absorption. Doubling the dose if a dose is missed can lead to overdose and adverse effects. Avoiding bananas is not specifically related to digoxin therapy.

4. When teaching a client with a new diagnosis of heart failure about dietary management, which of the following statements should the nurse include?

• A. Increase your intake of sodium-rich foods.
• B. Decrease your intake of sodium-rich foods.
• C. Avoid foods that contain lactose.
• D. Increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is to decrease the intake of sodium-rich foods. Sodium restriction is crucial in managing heart failure as it helps to reduce fluid retention and alleviate symptoms. Excessive sodium intake can lead to fluid buildup in the body, worsening heart failure. Therefore, advising the client to decrease sodium-rich foods is essential for their overall health and management of the condition. Choices A, C, and D are incorrect. Increasing intake of sodium-rich foods (Choice A) would worsen fluid retention and heart failure symptoms. Avoiding foods that contain lactose (Choice C) is not directly related to heart failure management through sodium restriction. Increasing intake of dairy products (Choice D) may not be suitable for all heart failure patients, especially if they need to limit saturated fats or cholesterol in their diet.

5. What action should be taken to prevent respiratory complications in a client who is postoperative?

• A. Encourage the use of an incentive spirometer.
• B. Restrict fluid intake.
• C. Place the client in a supine position.
• D. Administer a cough suppressant.

Correct answer: A

Rationale: Encouraging the use of an incentive spirometer is crucial in preventing respiratory complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, which can prevent atelectasis (lung collapse) and promote lung expansion. This, in turn, reduces the risk of respiratory complications such as pneumonia. Restricting fluid intake, placing the client in a supine position, and administering a cough suppressant are not appropriate actions for preventing respiratory complications in a postoperative client.

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