Nursing Elites

1. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?

• A. Apply a dry dressing.
• B. Cleanse the wound with normal saline.
• C. Perform debridement as needed.
• D. Apply a hydrocolloid dressing.

Correct answer: D

Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.

2. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in a private room with negative airflow.
• B. Wear an N95 respirator when caring for the client.
• C. Place the client in a positive pressure room.
• D. Maintain the client on droplet precautions.

Correct answer: A

Rationale: The correct answer is to place the client in a private room with negative airflow. This is crucial for preventing the spread of tuberculosis (TB) infection. Option B, wearing an N95 respirator when caring for the client, is important for staff protection but does not address the need for isolation precautions. Option C, placing the client in a positive pressure room, is incorrect as TB clients should be in negative pressure rooms to prevent the spread of airborne pathogens. Option D, maintaining the client on droplet precautions, is not sufficient for TB, which requires airborne precautions.

3. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following findings should the nurse identify as the cause of late decelerations?

• A. Fetal head compression
• B. Uteroplacental insufficiency
• C. Umbilical cord compression
• D. Fetal hypoxia

Correct answer: B

Rationale: Late decelerations in the fetal heart rate are caused by uteroplacental insufficiency, which results from inadequate blood flow to the placenta. This leads to reduced oxygen and nutrients reaching the fetus during contractions. Choice A, fetal head compression, does not typically cause late decelerations but can result in variable decelerations. Choice C, umbilical cord compression, usually leads to variable decelerations. Choice D, fetal hypoxia, is a broad term and not the direct cause of late decelerations, which are specifically linked to uteroplacental insufficiency.

4. A client is receiving chemotherapy and is being taught about preventing infection. Which of the following instructions should the nurse include?

• A. Take your temperature daily.
• B. Avoid fresh fruits and vegetables.
• C. Limit your intake of high-protein foods.
• D. Increase your intake of high-fat foods.

Correct answer: B

Rationale: Clients receiving chemotherapy are instructed to avoid fresh fruits and vegetables to lower the risk of infection. Fresh produce may harbor bacteria or other pathogens that could be harmful to individuals with compromised immune systems. Taking the temperature daily may be important but is not directly related to preventing infection. Limiting high-protein foods is not necessary unless there are specific dietary restrictions due to the treatment plan. Increasing the intake of high-fat foods is not recommended during chemotherapy as a high-fat diet may lead to other health issues.

5. A nurse is assessing a school-age child who has a urinary tract infection (UTI). Which of the following findings should the nurse expect?

• A. Periorbital edema.
• B. Decreased frequency of urination.
• C. Enuresis.
• D. Diarrhea.

Correct answer: C

Rationale: Enuresis is the correct finding to expect in a school-age child with a urinary tract infection. Enuresis, or involuntary urination, is a common symptom of UTIs in children. Periorbital edema (Choice A) is not typically associated with UTIs. Decreased frequency of urination (Choice B) is less likely in UTIs as there is often an increased urge to urinate. Diarrhea (Choice D) is not a common symptom of UTIs and is more indicative of gastrointestinal issues.

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