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. 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.

3. Prior to administering a blood transfusion, what should the healthcare professional do first?

• A. Prime the IV tubing with normal saline.
• B. Verify the client's identity.
• C. Obtain the blood product from the blood bank.
• D. Check the client's vital signs.

Correct answer: B

Rationale: Verifying the client's identity is the essential initial step before administering a blood transfusion. This action is crucial to confirm that the correct blood product is being administered to the right client, thereby preventing any potential errors or adverse reactions. Ensuring patient safety is paramount in healthcare, and verifying the client's identity is a fundamental safety measure that should always be prioritized.

4. A healthcare professional is assessing a client who has chronic pain. Which of the following findings should the healthcare professional expect?

• A. Hypotension
• B. Tachycardia
• C. Hyperthermia
• D. Depression

Correct answer: D

Rationale: The correct answer is D: Depression. Chronic pain is often associated with psychological effects like depression. Patients with chronic pain may experience feelings of hopelessness, helplessness, and despair, which are characteristic of depression. While chronic pain can lead to changes in vital signs like increased blood pressure and heart rate, hypotension, tachycardia, or hyperthermia are not typically expected findings solely due to chronic pain. Therefore, the healthcare professional should be alert to signs of depression in clients with chronic pain and address these psychological impacts appropriately.

5. A client receives discharge teaching on a new prescription for lisinopril. Which of the following instructions should be included?

• A. Avoid foods high in potassium.
• B. Take the medication with food.
• C. Increase your intake of salt.
• D. Take the medication at bedtime.

Correct answer: A

Rationale: The correct instruction that should be included when a client receives discharge teaching on a new prescription for lisinopril is to 'Avoid foods high in potassium.' Lisinopril, an ACE inhibitor, can lead to hyperkalemia by reducing potassium excretion. Therefore, clients taking lisinopril should be advised to avoid foods high in potassium to prevent potential complications associated with elevated potassium levels. Choices B, C, and D are incorrect because taking lisinopril with food, increasing salt intake, or taking the medication at bedtime are not specific instructions related to lisinopril therapy and may not be beneficial or necessary for the client's condition.

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