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 healthcare professional is preparing to administer a subcutaneous injection of insulin. Which of the following actions should the professional take?

• A. Use a 1-inch needle.
• B. Insert the needle at a 90-degree angle.
• C. Use a tuberculin syringe.
• D. Aspirate before injecting.

Correct answer: B

Rationale: When administering a subcutaneous injection, inserting the needle at a 90-degree angle is appropriate. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Using a 1-inch needle is common for subcutaneous injections to reach the subcutaneous fat layer adequately. Tuberculin syringes are typically used for intradermal injections, not subcutaneous injections. Aspirating before injecting is not necessary for subcutaneous injections as it is primarily used for intramuscular injections to ensure the needle is not in a blood vessel.

3. When caring for a client with a hearing impairment, which of the following actions should the nurse take when speaking with the client?

• A. Speak in a high-pitched voice.
• B. Exaggerate lip movements.
• C. Face the client when speaking.
• D. Use a monotone voice.

Correct answer: C

Rationale: When caring for a client with a hearing impairment, it is essential for the nurse to face the client when speaking. By facing the client, the nurse allows the individual to read lips and see facial expressions, which can significantly improve communication effectiveness. This approach facilitates better understanding and helps the client feel more connected during interactions. Speaking in a high-pitched voice (Choice A) is not recommended as it may distort speech sounds. Exaggerating lip movements (Choice B) can be patronizing and ineffective. Using a monotone voice (Choice D) lacks intonation that helps convey meaning and emotions in speech, making it harder for the client to understand.

4. A healthcare provider is caring for a client who has acute renal failure. Which of the following laboratory results should the healthcare provider expect?

• A. Decreased blood urea nitrogen (BUN)
• B. Decreased creatinine
• C. Increased potassium
• D. Increased calcium

Correct answer: C

Rationale: In acute renal failure, the kidneys are unable to excrete potassium efficiently, which can lead to hyperkalemia. As a result, an increased potassium level is a common finding in clients with acute renal failure. Hyperkalemia can have serious cardiac effects, making it essential for healthcare providers to monitor and manage potassium levels closely in clients with renal impairment. Choices A, B, and D are incorrect because in acute renal failure, blood urea nitrogen (BUN) and creatinine levels typically rise due to decreased renal function. Calcium levels are more likely to be decreased in acute renal failure due to impaired activation of vitamin D and subsequent decreased calcium absorption.

5. A client has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

• A. Apply a fecal collection system
• B. Apply a barrier cream
• C. Cleanse and dry the area
• D. Check the client's perineum

Correct answer: D

Rationale: When a client with major fecal incontinence reports irritation in the perianal area, the nurse's initial action should be to assess the client's perineum to gather more information. By checking the perineum, the nurse can identify the extent and nature of the irritation, allowing for appropriate interventions to be initiated. This assessment is crucial in developing a comprehensive care plan and addressing the client's immediate needs effectively. Applying the nursing process priority-setting framework helps in planning care and prioritizing nursing actions, making assessment the initial step in this scenario. Applying a fecal collection system (choice A) would be premature without assessing the perineal area first. Similarly, applying a barrier cream (choice B) or cleansing and drying the area (choice C) should follow the assessment to ensure appropriate interventions are chosen based on the assessment findings.

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