Nursing Elites

1. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?

• A. Proceed with the dressing change
• B. Restart the procedure if the sterile solution splashes onto the sterile field
• C. Continue without concern for minor splashes
• D. Delegate the task to another nurse

Correct answer: B

Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.

2. A nurse in an emergency department completes an assessment on an adolescent client with conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment?

• A. Tell me about your siblings
• B. Tell me what kind of music you like
• C. Tell me how often you drink alcohol
• D. Tell me about your school schedule

Correct answer: C

Rationale: The correct answer is C: 'Tell me how often you drink alcohol.' Alcohol use can exacerbate aggressive behaviors and is relevant for the assessment of suicide risk in adolescents with conduct disorders. Choices A, B, and D are unrelated to the assessment of suicide risk in this scenario and do not provide information that directly impacts the client's risk assessment.

3. A nurse is assessing a client with a history of heart failure. Which of the following findings should the nurse monitor?

• A. Increased energy
• B. Peripheral edema
• C. Elevated heart rate
• D. Improved lung sounds

Correct answer: B

Rationale: The correct answer is B: Peripheral edema. In heart failure, the heart's inability to pump effectively can lead to fluid backup, causing swelling in the extremities, known as peripheral edema. Monitoring for peripheral edema is crucial as it is a common sign of worsening heart failure. Choices A, C, and D are incorrect because increased energy, elevated heart rate, and improved lung sounds are not typical findings in heart failure. Increased energy is not usually associated with heart failure, an elevated heart rate may occur as a compensatory mechanism but is not a direct sign of heart failure, and improved lung sounds are not expected in heart failure which often presents with crackles or wheezes due to pulmonary congestion.

4. A client with rheumatoid arthritis is taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?

• A. Weight loss
• B. Hypoglycemia
• C. Hypertension
• D. Hyperkalemia

Correct answer: C

Rationale: The correct answer is C: Hypertension. Prednisone, a corticosteroid, can lead to hypertension as an adverse effect. Prednisone can cause sodium and water retention, leading to increased blood pressure. Options A, B, and D are incorrect. Weight loss is not typically associated with prednisone use; instead, weight gain is more common. Hypoglycemia is not a common adverse effect of prednisone; in fact, it can elevate blood sugar levels. Hyperkalemia is also not a typical adverse effect of prednisone; instead, it can cause hypokalemia, or low potassium levels.

5. A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of the following statements by the client indicates a need for further teaching?

• A. I will notify my doctor if I develop a cough.
• B. I will avoid using salt substitutes.
• C. I will increase my intake of potassium-rich foods.
• D. I will monitor my blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Clients taking lisinopril should avoid potassium-rich foods because ACE inhibitors can increase potassium levels, potentially leading to hyperkalemia. Choices A, B, and D are all correct statements. Clients should notify their doctor if they develop a cough as it can indicate a potential side effect of lisinopril. Avoiding salt substitutes is important as they may contain potassium chloride, which can also raise potassium levels. Monitoring blood pressure regularly is essential when taking an antihypertensive medication like lisinopril.

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