Nursing Elites

1. A nurse is providing dietary teaching to a client who has a new diagnosis of hypertension. Which of the following foods should the nurse instruct the client to avoid?

• A. Canned soup.
• B. Lean cuts of beef.
• C. Bananas.
• D. Baked chicken.

Correct answer: A

Rationale: The correct answer is A: Canned soup. Canned soups are usually high in sodium, which can increase blood pressure and should be avoided by clients with hypertension. Lean cuts of beef, bananas, and baked chicken are healthier options for individuals with hypertension as they are lower in sodium and can be included in a balanced diet to manage blood pressure levels.

2. What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?

• A. Apply hydrocolloid dressing
• B. Provide wound debridement
• C. Change the dressing daily
• D. Elevate the affected area

Correct answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.

3. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

• A. Diaphoresis
• B. Hypotension
• C. Urinary retention
• D. Tachycardia

Correct answer: C

Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.

4. A nurse is preparing to administer dopamine hydrochloride at 4 mcg/kg/min for a client weighing 80 kg. How many mL/hr should the nurse set the IV infusion to deliver?

• A. 6 mL/hr
• B. 8 mL/hr
• C. 12 mL/hr
• D. 16 mL/hr

Correct answer: A

Rationale: To calculate the correct rate, you first need to convert the weight to micrograms: 4 mcg/kg/min * 80 kg = 320 mcg/min. Then, convert micrograms to milligrams: 320 mcg/min / 1000 = 0.32 mg/min. Next, calculate how many milligrams per hour: 0.32 mg/min * 60 min/hr = 19.2 mg/hr. Finally, determine the mL/hr rate by using the concentration provided: 19.2 mg/hr / 800 mg in 250 mL = 6 mL/hr. Therefore, the correct answer is 6 mL/hr. Choice B, 8 mL/hr, is incorrect as it does not reflect the accurate calculation based on the weight and drug concentration. Choices C and D, 12 mL/hr and 16 mL/hr, are also incorrect as they do not align with the correct calculation of the infusion rate for dopamine hydrochloride based on the client's weight and the medication concentration.

5. A nurse is preparing a sterile field for a client with a surgical wound. Which of the following actions should the nurse take to maintain the sterile field?

• A. Open sterile packages using the flap closest to your body first.
• B. Don sterile gloves before opening the sterile package.
• C. Avoid reaching over the sterile field.
• D. Place sterile items at least 2.5 cm (1 in) from the edge of the sterile field.

Correct answer: C

Rationale: The correct action to maintain a sterile field is to avoid reaching over it. This prevents contamination of the sterile environment by reducing the risk of unintentionally dropping microorganisms from non-sterile areas onto the sterile field. Opening sterile packages using the flap closest to your body first (choice A) is a good practice but not directly related to maintaining the sterile field. Donning sterile gloves before opening the sterile package (choice B) is crucial for maintaining sterility but not specific to maintaining the sterile field. Placing sterile items at least 2.5 cm (1 in) from the edge of the sterile field (choice D) is important to prevent accidental contamination, but it is not the primary action to maintain the sterile field.

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