Nursing Elites

1. A client with diabetes mellitus is receiving education from a nurse on preventing long-term complications. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will keep my blood glucose levels within the target range.
• B. I will check my feet daily for any open sores or wounds.
• C. I will monitor my blood pressure regularly.
• D. I will consume foods that are high in fiber.

Correct answer: B

Rationale: The correct answer is B: 'I will check my feet daily for any open sores or wounds.' This statement shows an understanding of the importance of foot care in preventing complications like diabetic foot ulcers. Monitoring blood glucose levels (choice A) is crucial but not directly related to foot care. Monitoring blood pressure (choice C) is important for overall health but does not specifically address preventing long-term complications of diabetes. Consuming foods high in fiber (choice D) is beneficial for managing blood sugar levels but does not directly address preventing foot complications.

2. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 110/70 mm Hg
• B. Heart rate of 88/min
• C. Respiratory rate of 20/min
• D. Temperature of 37.3°C (99.1°F)

Correct answer: D

Rationale: The correct answer is D because a temperature of 37.3°C (99.1°F) is slightly elevated, indicating a possible infection or inflammatory response, which should be reported to the provider for further evaluation. Choices A, B, and C are within normal limits for a client postoperative, so they do not require immediate reporting. Elevated temperature can be a sign of infection or other complications, making it a priority for reporting and further assessment.

3. A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?

• A. Instruct the client to use an alcohol-free mouthwash.
• B. Apply heat packs to the radiation site.
• C. Provide a diet low in carbohydrates.
• D. Avoid exposure to direct sunlight during treatment.

Correct answer: D

Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.

4. A nurse is providing teaching to a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

• A. Avoid eating foods high in potassium.
• B. Avoid drinking alcohol while taking this medication.
• C. Take this medication with a full glass of water.
• D. Take this medication with a full glass of water.

Correct answer: C

Rationale: The correct answer is C. Clients taking clopidogrel should take the medication with a full glass of water to prevent gastrointestinal irritation. Choice A is incorrect because there is no specific recommendation to avoid foods high in potassium with clopidogrel. Choice B is unrelated to the medication's administration. Choice D is a duplication of choice C, providing no additional information.

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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