Nursing Elites

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

• A. Massage the ulcer
• B. Apply a heating pad
• C. Reposition the client every 2 hours
• D. Use alcohol-based cleansers

Correct answer: C

Rationale: Repositioning the client every 2 hours is a crucial intervention in the management of pressure ulcers. This action helps redistribute pressure, reducing the risk of further skin breakdown and promoting wound healing. Massaging the ulcer can cause further damage to the skin and underlying tissues. Applying a heating pad can increase the risk of skin breakdown and should be avoided. Alcohol-based cleansers are too harsh for pressure ulcers and can irritate the skin, potentially delaying healing.

2. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?

• A. Tremors
• B. Urine retention
• C. Kussmaul respirations
• D. Bradypnea

Correct answer: C

Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.

3. A client with hypertension is being taught about the DASH diet. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of sodium-rich foods.
• B. I should decrease my intake of potassium-rich foods.
• C. I should increase my intake of fruits and vegetables.
• D. I should decrease my intake of whole grains.

Correct answer: C

Rationale: The correct answer is C. The Dietary Approaches to Stop Hypertension (DASH) diet is recommended for managing hypertension. Increasing the intake of fruits and vegetables is a key component of the DASH diet as these foods are rich in nutrients that can help lower blood pressure levels. Choices A, B, and D are incorrect because they go against the principles of the DASH diet, which focuses on reducing sodium intake, increasing potassium-rich foods, and consuming whole grains.

4. 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.

5. Which of the following statements indicates the client understands the colostomy care instructions?

• A. I will change the colostomy bag once a week.
• B. I will avoid eating high-fiber foods.
• C. I will clean around the stoma with mild soap and water.
• D. I will apply lotion to the skin around the stoma.

Correct answer: C

Rationale: The correct answer is C. Cleaning around the stoma with mild soap and water is crucial for colostomy care as it helps prevent infection and skin irritation. Changing the colostomy bag frequency, dietary modifications, or applying lotion are not primary aspects of stoma care. Proper cleaning around the stoma helps maintain hygiene and prevents complications, making it a key component of caring for a colostomy.

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