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 assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 91%
• B. Use of pursed-lip breathing
• C. Productive cough with green sputum
• D. Decreased breath sounds in the right lower lobe

Correct answer: D

Rationale: The correct finding the nurse should report to the provider is decreased breath sounds in the right lower lobe. This can indicate a respiratory infection or atelectasis in clients with COPD, requiring further evaluation and intervention. Choice A, an oxygen saturation of 91%, although slightly lower than normal, does not necessarily require immediate reporting unless the client's baseline is significantly higher. Choice B, the use of pursed-lip breathing, is actually a beneficial technique for clients with COPD to improve oxygenation and reduce shortness of breath, so it does not need reporting. Choice C, a productive cough with green sputum, can be common in clients with COPD and may indicate an infection, but it is not as concerning as decreased breath sounds in a specific lung lobe which may signify a more acute issue.

3. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse rate every 30 minutes.
• C. Obtain a prescription for restraint within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: C

Rationale: When caring for a client with bipolar disorder experiencing acute mania and having obtained a verbal prescription for restraints, the nurse must ensure to obtain a formal written prescription for restraint within 4 hours. This is crucial to maintain the safety and proper care of the client. Choices A, B, and D are incorrect because renewing the prescription every 8 hours, checking pulse rate every 30 minutes, and documenting the client's condition every 15 minutes do not address the immediate need for a formal restraint prescription within 4 hours to manage the client's acute mania effectively.

4. How should signs of infection in a post-surgical patient be assessed?

• A. Check the surgical site
• B. Check the patient's vital signs
• C. Monitor for fever
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.

5. While caring for a client receiving hemodialysis, which action should the nurse include in the plan of care?

• A. Withhold all medications until after dialysis.
• B. Check the vascular access site for bleeding after dialysis.
• C. Rehydrate with dextrose 5% in water for hypotension.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: B

Rationale: The correct action the nurse should include in the plan of care when caring for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial to monitor for any signs of bleeding or complications at the access site. Withholding all medications until after dialysis (Choice A) is not necessary unless specified for certain medications. Rehydrating with dextrose 5% in water for hypotension (Choice C) is not appropriate for addressing hypotension related to hemodialysis. Giving an antibiotic 30 minutes before dialysis (Choice D) is not typically indicated unless there is a specific medical indication for prophylactic antibiotic use.

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