Nursing Elites

1. A nurse is providing teaching to a client who has type 1 diabetes mellitus about foot care. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water daily.
• B. Wear cotton socks.
• C. Trim your toenails straight across.
• D. Apply lotion to your feet after bathing.

Correct answer: C

Rationale: The correct answer is C: 'Trim your toenails straight across.' Trimming toenails straight across helps prevent ingrown toenails, which is important for clients with diabetes to prevent infections. Choice A is incorrect because soaking feet in warm water can lead to skin breakdown and infections. Choice B is incorrect as cotton socks can retain moisture, increasing the risk of fungal infections. Choice D is also incorrect as applying lotion between the toes can create a moist environment, increasing the risk of infections.

2. A nurse is assessing a client who is receiving furosemide for heart failure. Which of the following findings is the priority to report to the provider?

• A. Blood pressure of 98/58 mm Hg
• B. Urine output of 50 mL/hr
• C. Serum potassium level of 3.2 mEq/L
• D. Weight loss of 0.5 kg (1.1 lb) in 24 hours

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L indicates hypokalemia, a potential complication of furosemide therapy, and should be reported immediately. Hypokalemia can lead to serious cardiac dysrhythmias. Choices A, B, and D are important assessments but are not as critical as managing serum potassium levels in a client receiving furosemide for heart failure.

3. A nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?

• A. Monitor the client's urinary output.
• B. Assist the client to splint the incision with a pillow when coughing.
• C. Provide the client with a clear liquid diet.
• D. Encourage the client to ambulate in the hallway.

Correct answer: B

Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.

4. What is the best way to manage a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Apply compression stockings
• C. Encourage ambulation
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is A: Administer anticoagulants. Administering anticoagulants is crucial in managing patients with suspected DVT as it helps prevent further clot formation and reduces the risk of complications like pulmonary embolism. Choice B, applying compression stockings, is more focused on preventing DVT in high-risk patients rather than managing an established case. Encouraging ambulation, choice C, is beneficial in the prevention of DVT but is not the primary management for suspected cases. Monitoring oxygen saturation, choice D, is important in overall patient care but is not the primary intervention for suspected DVT.

5. A client is being taught how to perform self-catheterization. Which of the following instructions should the nurse include?

• A. Clean the catheter with alcohol after each use.
• B. Perform self-catheterization while sitting on the toilet.
• C. Use a new catheter each time you perform self-catheterization.
• D. Lubricate the catheter tip with petroleum jelly before insertion.

Correct answer: C

Rationale: The correct answer is C: 'Use a new catheter each time you perform self-catheterization.' It is essential to use a new, sterile catheter each time to prevent infection during the procedure. Choice A is incorrect because cleaning the catheter with alcohol may not be sufficient to prevent infection. Choice B is incorrect because self-catheterization is typically done in a clean, private area, not necessarily on the toilet. Choice D is incorrect because lubricating the catheter tip with petroleum jelly is a common practice but not as crucial as using a new catheter each time to prevent infection.

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