Nursing Elites

1. A client has a stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?

• A. Apply a heat lamp to the area for 20 minutes each day.
• B. Change the dressing on the heel every 12 hours.
• C. Apply a transparent dressing over the heel.
• D. Use a water pressure mattress.

Correct answer: C

Rationale: Applying a transparent dressing over the heel is beneficial as it can protect the ulcer from friction and shear, and allow for continuous observation of the wound. This intervention promotes healing and prevents further damage to the skin. Choice A is incorrect because applying heat can increase the risk of tissue damage and should be avoided. Choice B is incorrect as changing the dressing every 12 hours may disrupt the wound healing process and is not necessary for a stage 1 pressure ulcer. Choice D is incorrect because using a water pressure mattress is not a specific intervention for a stage 1 pressure ulcer on the heel.

2. A client with a new diagnosis of hypothyroidism is being taught about medication management. Which of the following statements should the nurse include in the teaching?

• A. You should take your medication with a high-fiber meal.
• B. You should take your medication on an empty stomach.
• C. You should take your medication with a calcium supplement.
• D. You should take your medication before bedtime.

Correct answer: B

Rationale: The correct answer is B: 'You should take your medication on an empty stomach.' When educating a client with hypothyroidism, it is essential to advise taking thyroid medication on an empty stomach to enhance absorption and effectiveness. Taking the medication with food, especially high-fiber or with supplements like calcium, can interfere with absorption and reduce its efficacy. Therefore, it is crucial for the client to follow the recommendation of taking the medication on an empty stomach. Choices A, C, and D are incorrect because taking the medication with a high-fiber meal (Choice A) or with a calcium supplement (Choice C) can hinder absorption, and taking it before bedtime (Choice D) does not optimize absorption compared to taking it on an empty stomach.

3. 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.

4. When teaching a client with a new diagnosis of diabetes mellitus about foot care, which of the following instructions should the nurse include?

• A. Soak your feet in hot water every day.
• B. Apply lotion between your toes.
• C. Inspect your feet daily.
• D. Use over-the-counter products to remove corns.

Correct answer: C

Rationale: Inspecting the feet daily is crucial for clients with diabetes mellitus to detect early signs of injury or infection promptly. This practice helps prevent serious complications such as diabetic foot ulcers. Soaking feet in hot water daily can lead to skin dryness and increase the risk of injury. Applying lotion between toes can cause moisture buildup, leading to fungal infections. Using over-the-counter products to remove corns can result in skin damage and should be done under healthcare provider supervision.

5. 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.

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