Nursing Elites

1. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Apply a moisture-retentive dressing
• C. Apply a heating pad to the site
• D. Keep the client on bedrest

Correct answer: B

Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.

2. A nurse enters a client's room and sees smoke coming from the trash can. What action should the nurse take first?

• A. Call for assistance
• B. Evacuate the room
• C. Attempt to put out the fire
• D. Turn off the oxygen supply

Correct answer: B

Rationale: In the event of a fire, the priority is to ensure everyone's safety. Therefore, the nurse's initial action should be to evacuate the room. Calling for assistance can be done while evacuating, ensuring help is on the way. Attempting to put out the fire can be dangerous and may delay evacuation. Turning off the oxygen supply is not the first step in this situation, as the immediate concern is to remove individuals from the potential danger.

3. A nurse is caring for a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?

• A. Irrigate the catheter with normal saline
• B. Notify the provider
• C. Apply a warm compress to the site
• D. Administer pain medication

Correct answer: B

Rationale: The correct first action for the nurse to take when a client reports pain at the site of an indwelling urinary catheter is to notify the provider. Pain at the catheter site may indicate complications such as infection or blockage, which require further assessment and intervention by the healthcare provider. Irrigating the catheter, applying a warm compress, or administering pain medication should not be done without provider evaluation as they do not address the underlying cause of the pain and may potentially worsen the situation.

4. A nurse is monitoring a client who is receiving continuous enteral feedings. What finding suggests the client is not tolerating the feeding?

• A. Increased bowel sounds
• B. Nausea
• C. Elevated blood pressure
• D. Fever

Correct answer: B

Rationale: Nausea is a common sign indicating that the client is not tolerating enteral feedings well. It can be a result of various issues such as feeding intolerance, infection, or other underlying conditions. Nausea should be promptly addressed to prevent further complications. Increased bowel sounds (Choice A) are not typically indicative of feeding intolerance. Elevated blood pressure (Choice C) and fever (Choice D) are generally not directly related to enteral feeding intolerance unless there are specific underlying conditions contributing to them.

5. A client scheduled for cataract surgery tells the nurse, 'I see just fine and have decided to cancel my surgery.' What should the nurse do?

• A. Proceed with the surgery as planned
• B. Document the refusal and inform the surgeon
• C. Explain the benefits of the surgery
• D. Respect the client's decision

Correct answer: C

Rationale: In this scenario, the nurse should explain the benefits of the surgery to the client. By providing more information, the client may reconsider their decision after understanding the positive impact the surgery could have on their vision. Proceeding with the surgery against the client's wishes (Choice A) is not ethical and goes against the principle of autonomy. While documenting the refusal and informing the surgeon (Choice B) is important for the client's medical record, it is crucial to first try to educate the client about the benefits. Simply respecting the client's decision (Choice D) without attempting to provide more information may not be in the client's best interest.

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