Nursing Elites

1. A nurse is providing teaching to a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

• A. Apply the patch to your upper arm.
• B. You should remove the patch before showering.
• C. Rotate the patch site each time you apply it.
• D. Apply the patch to your lower abdomen.

Correct answer: C

Rationale: The correct answer is to instruct the client to rotate the patch site each time they apply it. This practice helps prevent skin irritation and ensures the effectiveness of nitroglycerin transdermal patches. Applying the patch to the same site each time can lead to skin irritation and decreased patch efficacy. Choices A, B, and D are incorrect because applying the patch to the upper arm, removing it before showering, and placing it on the lower abdomen do not promote proper rotation of patch sites, which is essential for optimal outcomes.

2. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include?

• A. Cleanse the wound with povidone-iodine.
• B. Apply a hydrocolloid dressing.
• C. Perform debridement as needed.
• D. Keep the wound open to air.

Correct answer: B

Rationale: The correct answer is B: Apply a hydrocolloid dressing. Applying a hydrocolloid dressing helps create a moist environment that promotes healing in clients with stage 2 pressure injuries. Choice A, cleansing the wound with povidone-iodine, is not recommended for stage 2 pressure injuries as it can be too harsh on the skin. Performing debridement as needed, as mentioned in choice C, is not typically indicated for stage 2 pressure injuries, which involve partial-thickness skin loss. Keeping the wound open to air, as stated in choice D, is also not the preferred approach for managing stage 2 pressure injuries, as maintaining a moist environment is key to promoting healing.

3. A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old. Which of the following actions should the nurse take?

• A. Allow the child to handle the IV supplies to become familiar with them.
• B. Tell the child they will feel discomfort during the catheter insertion.
• C. Use a mummy restraint to hold the child during the catheter insertion.
• D. Require the parents to leave the room during the procedure.

Correct answer: B

Rationale: The correct answer is B because informing the child that they will feel discomfort during catheter insertion is crucial to prepare them for the procedure. Choice A is incorrect as children should not handle medical supplies. Choice C is inappropriate as using a restraint can cause anxiety and fear in the child. Choice D is not necessary as having parents present can provide comfort and support to the child during the procedure.

4. A client is being discharged with a new prescription for metoprolol. Which of the following instructions should the nurse include?

• A. Do not discontinue this medication suddenly.
• B. Take this medication in the evening to decrease the risk of falls.
• C. Monitor your heart rate before taking this medication.
• D. Avoid grapefruit juice while taking this medication.

Correct answer: C

Rationale: The correct instruction for a client prescribed metoprolol is to monitor their heart rate before taking the medication. Metoprolol is a beta-blocker that can cause bradycardia (slow heart rate), so it is essential for clients to check their heart rate before each dose. Choice A is incorrect because abruptly stopping metoprolol can lead to adverse effects, so it should not be discontinued suddenly. Choice B is incorrect because there is no specific recommendation to take metoprolol at night to reduce falls. Choice D is incorrect because grapefruit juice can interact with metoprolol, affecting its absorption, and should be avoided.

5. A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect?

• A. Increased urine output.
• B. Hyperactive reflexes.
• C. Hypoactive bowel sounds.
• D. Facial weakness.

Correct answer: D

Rationale: Facial weakness is a common finding in clients with Guillain-Barré syndrome due to muscle weakness. While increased urine output is not typically associated with Guillain-Barré syndrome, hyperactive reflexes are more indicative of conditions like hyperthyroidism or spinal cord injury. Hypoactive bowel sounds are not a classic finding in Guillain-Barré syndrome, making it an incorrect choice.

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