Nursing Elites

1. A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?

• A. Irrigate the wound with normal saline.
• B. Apply a wet-to-dry gauze dressing.
• C. Use a cotton ball to cleanse the wound.
• D. Administer an analgesic after the dressing change.

Correct answer: A

Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.

2. A client with diabetes is being discharged. What is the most important teaching point?

• A. Monitor blood sugar levels once in the morning
• B. Administer insulin before meals as prescribed
• C. Take medication only when feeling unwell
• D. Monitor glucose levels weekly

Correct answer: B

Rationale: The most important teaching point for a client with diabetes being discharged is to administer insulin before meals as prescribed. This is crucial for managing blood sugar levels effectively and preventing complications. Monitoring blood sugar levels once in the morning (Choice A) is not sufficient for proper diabetes management, as levels can fluctuate throughout the day. Taking medication only when feeling unwell (Choice C) is not recommended as diabetes treatment is based on a regular schedule. Monitoring glucose levels weekly (Choice D) is not frequent enough to provide the necessary information for managing diabetes on a day-to-day basis.

3. A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following instructions should the nurse include?

• A. Use oils with trans fats
• B. Choose lean cuts of beef
• C. Avoid purchasing beef that is a loin cut
• D. Purchase chicken instead of lamb

Correct answer: B

Rationale: The correct answer is B: 'Choose lean cuts of beef.' Selecting lean cuts of beef is crucial in reducing solid fat consumption for individuals with high cholesterol levels. Lean cuts contain less saturated fat compared to fatty cuts, thus aiding in managing cholesterol levels. Option A is incorrect as oils with trans fats should be avoided since they contribute to unhealthy fats. Option C is not directly related to reducing solid fat consumption. Option D, while suggesting a leaner meat option, does not address the issue of solid fat consumption as directly as choosing lean cuts of beef.

4. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?

• A. Document the client's condition every 15 minutes.
• B. Attach the restraints to a non-moving part of the bed.
• C. Avoid requesting a PRN restraint prescription for clients who are aggressive.
• D. Remove the client's restraints based on the client's condition.

Correct answer: A

Rationale: The correct answer is A: Document the client's condition every 15 minutes. When using belt restraints, it is crucial to document the client's condition regularly to ensure their safety and well-being. This guideline allows for ongoing assessment of the client's need for restraints and any potential adverse effects. Choice B is incorrect as restraints should not be attached to the bed frame but to a non-moving part of the bed to prevent harm in case of bed movement. Choice C is incorrect as PRN (as needed) restraint prescription should not be a routine practice and should only be considered after other interventions have been attempted. Choice D is incorrect as restraints should be removed and reevaluated based on the client's condition, not solely on a fixed time schedule.

5. A client with an NG tube is reporting nausea and a decrease in gastric secretions. What is the nurse's first action?

• A. Increase the suction pressure
• B. Irrigate the NG tube with sterile water
• C. Turn the client onto their left side
• D. Replace the NG tube with a new one

Correct answer: B

Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This helps alleviate blockages and can improve the client's symptoms. Increasing the suction pressure (Choice A) may exacerbate the issue and cause further discomfort. Turning the client onto their left side (Choice C) is not directly related to addressing the reported symptoms. Replacing the NG tube with a new one (Choice D) should be considered only after attempting initial interventions like irrigation.

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