Nursing Elites

1. A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?

• A. Cleanse the wound with povidone-iodine solution daily.
• B. Irrigate the wound with hydrogen peroxide.
• C. Reposition the client every 4 hours.
• D. Apply a moisture barrier ointment.

Correct answer: D

Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.

2. A nurse is caring for a client who is 1 day postoperative following abdominal surgery. The nurse should suspect that the client has developed an infection based on which of the following findings?

• A. Blood pressure of 110/70 mm Hg
• B. Temperature of 38.5°C (101.3°F)
• C. Heart rate of 92/min
• D. Drainage at the surgical site

Correct answer: B

Rationale: An elevated temperature of 38.5°C (101.3°F) is indicative of infection postoperatively. Fever is a common sign of infection, and temperatures above the normal range should raise suspicion. The other vital signs (blood pressure, heart rate) may be within an acceptable range, and some drainage at the surgical site can be expected postoperatively. However, the elevated temperature is a more specific indicator of a potential infection that requires immediate attention.

3. A nurse is caring for a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min, and the PR interval is 0.24 seconds. What cardiac rhythm should the nurse interpret this finding as?

• A. First-degree AV block.
• B. Premature ventricular contraction.
• C. Sinus bradycardia.
• D. Atrial fibrillation.

Correct answer: A

Rationale: The correct answer is A: First-degree AV block. A PR interval of 0.24 seconds indicates a prolonged PR interval, which is characteristic of first-degree AV block. This rhythm is considered benign and often does not require treatment. Choice B, premature ventricular contraction, is characterized by early, abnormal ventricular contractions and would not be indicated by the findings provided. Choice C, sinus bradycardia, would present with a normal PR interval but a heart rate less than 60 beats per minute. Choice D, atrial fibrillation, is characterized by an irregularly irregular rhythm with no identifiable P waves, which does not align with the findings of a prolonged PR interval in this scenario.

4. A nurse is caring for a client who is receiving furosemide. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?

• A. Serum sodium.
• B. Serum glucose.
• C. Serum potassium.
• D. Serum calcium.

Correct answer: C

Rationale: The correct answer is C: Serum potassium. Furosemide is a potassium-wasting diuretic, meaning it can lead to potassium loss in the body. Monitoring serum potassium levels is crucial to evaluate the effectiveness of furosemide and prevent hypokalemia. Options A, B, and D are incorrect because furosemide does not directly affect sodium, glucose, or calcium levels in the same way it impacts potassium levels.

5. A client who is 14 weeks of gestation reports swelling of the face. What should the nurse do next?

• A. Administer an analgesic.
• B. Report this finding to the provider immediately.
• C. Administer an antiemetic.
• D. Monitor the client's vital signs.

Correct answer: B

Rationale: The correct answer is to report this finding to the provider immediately. Swelling of the face in pregnancy can be a sign of preeclampsia, a serious condition characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Prompt reporting and intervention are crucial to prevent complications for both the client and the fetus. Administering an analgesic (choice A) is not appropriate for this situation as it does not address the underlying cause of the swelling. Administering an antiemetic (choice C) is used to treat nausea and vomiting, which are not the primary concerns associated with facial swelling in this scenario. Monitoring the client's vital signs (choice D) is important but should be done after reporting the finding to the provider to guide further assessment and management.

Similar Questions