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 healthcare provider is preparing to administer an intramuscular injection to an adult client. Which of the following injection sites should the healthcare provider select?

• A. Deltoid muscle
• B. Dorsogluteal muscle
• C. Vastus lateralis muscle
• D. Rectus femoris muscle

Correct answer: A

Rationale: The deltoid muscle is a common site for intramuscular injections in adults due to its accessibility and muscle mass. It is located in the upper arm and provides a sufficient area for injection. The deltoid muscle is preferred for administering vaccines and other medications that require IM administration. Choice B, the dorsogluteal muscle, is not recommended for intramuscular injections due to the proximity of major nerves and blood vessels in that area, which can lead to nerve damage or injury. Choice C, the vastus lateralis muscle, is more commonly used for infants and young children, while choice D, the rectus femoris muscle, is not typically used for intramuscular injections in adults.

3. A client with cirrhosis is being taught about dietary management. 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 sodium-rich foods.
• C. I should increase my intake of potassium-rich foods.
• D. I should decrease my intake of potassium-rich foods.

Correct answer: B

Rationale: The correct answer is B. In cirrhosis, decreasing the intake of sodium-rich foods is essential to manage fluid retention and symptoms. Excessive sodium intake can worsen fluid accumulation and lead to complications such as ascites. Therefore, advising the client to decrease sodium-rich foods demonstrates an understanding of the dietary management necessary for cirrhosis. Choices A, C, and D are incorrect because increasing sodium-rich foods can exacerbate fluid retention and complications in cirrhosis, increasing potassium-rich foods is not the primary focus of dietary management in cirrhosis, and decreasing potassium-rich foods is not a key recommendation for managing cirrhosis-related dietary issues.

4. A client with peptic ulcer disease is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should avoid drinking milk.
• B. I should avoid drinking coffee.
• C. I should avoid eating high-fiber foods.
• D. I should avoid eating low-fat foods.

Correct answer: B

Rationale: The correct answer is B. Avoiding coffee is important in managing peptic ulcer disease as it helps reduce acid production and alleviate symptoms. Coffee is known to stimulate acid secretion in the stomach, which can exacerbate ulcer symptoms. Therefore, instructing the client to avoid drinking coffee is essential in the dietary management of peptic ulcer disease. Choices A, C, and D are incorrect. Drinking milk is generally allowed and can even provide a protective effect against ulcers. High-fiber foods are beneficial for digestion and do not need to be avoided unless they cause discomfort. Low-fat foods are also typically recommended for individuals with peptic ulcer disease as they are easier on the digestive system.

5. A client with diverticulitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of high-fiber foods.
• B. I should decrease my intake of high-fiber foods.
• C. I should increase my intake of high-fat foods.
• D. I should decrease my intake of high-fat foods.

Correct answer: A

Rationale: The correct answer is A. Increasing intake of high-fiber foods is essential in managing diverticulitis as it helps prevent constipation and promotes bowel regularity, reducing the risk of complications and improving overall colon health. Choice B is incorrect because decreasing high-fiber foods can worsen diverticulitis symptoms. Choices C and D are also incorrect as increasing high-fat foods can exacerbate diverticulitis, while decreasing high-fat foods is generally recommended to manage the condition.

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