Nursing Elites

1. A nurse is teaching a client with diabetes mellitus about foot care. What is the most important instruction the nurse should include?

• A. Apply lotion between the toes after bathing
• B. Inspect feet daily for injuries
• C. Wear shoes only indoors
• D. Cut toenails in a rounded shape

Correct answer: B

Rationale: Inspecting feet daily for injuries is crucial for clients with diabetes to prevent unnoticed wounds from becoming infected. This instruction is the most important as it helps in early detection and management of foot problems. Choice A is incorrect because applying lotion between the toes can lead to excessive moisture, increasing the risk of fungal infections. Choice C is wrong as wearing shoes indoors can also lead to foot issues. Choice D is incorrect because cutting toenails in a rounded shape can result in ingrown toenails, posing a risk for infection.

2. A nurse is providing discharge teaching for a client with a prescription for home oxygen therapy. Which instruction should the nurse include?

• A. Increase the oxygen flow rate when shortness of breath occurs
• B. Keep oxygen tubing away from heat sources
• C. Wear synthetic fabrics to prevent static
• D. Turn off the oxygen when not in use

Correct answer: B

Rationale: The correct instruction for a client with home oxygen therapy is to keep oxygen tubing away from heat sources to prevent fires and other hazards. Option A is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Option C is incorrect as synthetic fabrics can generate static electricity, which is a fire hazard. Option D is incorrect as oxygen should be left on as prescribed unless advised otherwise.

3. A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. Which term should the nurse use to document this finding?

• A. Papule
• B. Macule
• C. Nodule
• D. Tumor

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion is less than 0.5cm, fitting the description of a macule. A papule (choice A) is a solid, elevated lesion less than 0.5 cm in diameter. A nodule (choice C) is a solid, elevated lesion that is 0.5 cm or larger in diameter. A tumor (choice D) refers to a mass of abnormal tissue growth, which is not applicable in this scenario.

4. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?

• A. Bladder spasms
• B. Bladder distention
• C. Frequent urination
• D. Hematuria

Correct answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention is a sign of catheter occlusion because it indicates a failure to drain urine properly. Bladder spasms (Choice A) are more commonly associated with bladder irritability rather than catheter occlusion. Frequent urination (Choice C) is unlikely in a client with an indwelling catheter as the urine should be draining continuously. Hematuria (Choice D) refers to blood in the urine and is not typically a direct sign of catheter occlusion.

5. A nurse is assessing a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?

• A. Nausea
• B. Decreased heart rate
• C. Weight gain
• D. Fever

Correct answer: A

Rationale: Nausea is a common symptom of intolerance to enteral feedings. When a client experiences nausea during enteral feeding, it can indicate issues such as feeding tube placement problems, formula intolerance, or gastroparesis. Nausea can lead to vomiting and further complications if not addressed promptly. Decreased heart rate, weight gain, and fever are not typically associated with intolerance to enteral feedings and would not be the primary indicators for this situation.

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