Nursing Elites

1. A client with diabetes mellitus is being taught about foot care by a nurse. Which instruction should the nurse include?

• A. Cut toenails straight across
• B. Wear shoes at all times
• C. Apply lotion between the toes
• D. Soak feet in hot water daily

Correct answer: B

Rationale: The correct answer is to 'Wear shoes at all times.' This instruction is crucial for preventing foot injuries in clients with diabetes mellitus. Wearing shoes protects the feet from potential injuries and reduces the risk of developing foot ulcers. Cutting toenails straight across (not in a rounded shape) helps prevent ingrown toenails. Applying lotion between the toes can create a moist environment, increasing the risk of fungal infections. Soaking feet in hot water daily can lead to dry skin and potentially cause burns, which is not recommended for individuals with diabetes.

2. During a focused assessment for a client with dysrhythmias, what indicates ineffective cardiac contractions?

• A. Increased heart rate
• B. Pulse deficit
• C. Elevated blood pressure
• D. Bounding pulse

Correct answer: B

Rationale: A pulse deficit is a crucial finding in clients with dysrhythmias as it indicates ineffective cardiac contractions. A pulse deficit occurs when the apical heart rate is faster than the radial pulse rate, suggesting that some heartbeats are not generating a pulse. This can be a sign of serious heart conditions like atrial fibrillation or heart failure. The other options, such as an increased heart rate (choice A), elevated blood pressure (choice C), and bounding pulse (choice D), do not specifically indicate ineffective cardiac contractions and are not directly associated with dysrhythmias.

3. A client is reviewing a medical record for advance directives. Which client statement indicates an understanding of the teaching?

• A. I don't need a living will because my family will make decisions.
• B. My living will takes effect only if I lose consciousness.
• C. My family will decide when to follow my living will.
• D. I can change my living will at any time.

Correct answer: D

Rationale: The correct answer is D because clients can change their living will at any time as long as they are mentally competent. Choice A is incorrect because relying solely on family to make decisions may not align with the client's wishes. Choice B is incorrect because a living will can address various situations, not just loss of consciousness. Choice C is incorrect because the client should be the primary decision-maker regarding their living will, not the family.

4. A nurse is providing discharge instructions to a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?

• A. Steamed carrots
• B. Orange slices
• C. Mashed potatoes
• D. Baked chicken

Correct answer: B

Rationale: The correct answer is B: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices fall into this category due to their texture and potential choking hazard. Steamed carrots, mashed potatoes, and baked chicken are typically suitable for a mechanical soft diet as they can be easily mashed or cut into small, manageable pieces for consumption.

5. 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.

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