Nursing Elites

1. A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?

• A. Reposition the client every 4 hours
• B. Apply lotion to the skin every 2 hours
• C. Use a special mattress to reduce pressure on the skin
• D. Increase fluid intake to promote skin hydration

Correct answer: C

Rationale: The correct answer is C: 'Use a special mattress to reduce pressure on the skin.' This intervention is crucial in preventing skin breakdown in clients with limited mobility as it helps to reduce pressure on bony prominences. Repositioning every 4 hours (Choice A) is important but may not be sufficient to prevent skin breakdown entirely. Applying lotion every 2 hours (Choice B) may not address the root cause of skin breakdown related to pressure. Increasing fluid intake (Choice D) is beneficial for overall skin health but may not directly prevent skin breakdown caused by pressure points.

2. A nurse is caring for a client who is undergoing surgery for a hip fracture. What is a priority intervention to reduce the risk of postoperative complications?

• A. Encourage early ambulation
• B. Provide intravenous antibiotics
• C. Apply anti-embolism stockings
• D. Place a Foley catheter to monitor output

Correct answer: A

Rationale: Encouraging early ambulation is crucial in reducing the risk of postoperative complications, such as blood clots and pneumonia. Early mobilization helps prevent complications like deep vein thrombosis and pneumonia by promoting circulation and preventing respiratory complications. Providing intravenous antibiotics (Choice B) is important for preventing infections but is not the priority immediately post-surgery. Applying anti-embolism stockings (Choice C) is beneficial in preventing venous thromboembolism but does not address the immediate need for mobility. Placing a Foley catheter (Choice D) may be necessary during surgery but is not a priority intervention to reduce postoperative complications related to immobility.

3. A healthcare professional is reviewing the lab results of a client who has been experiencing a fever for 3 days. What finding indicates fluid volume deficit (FVD)?

• A. Decreased hematocrit
• B. Increased white blood cell count
• C. Increased hematocrit
• D. Decreased white blood cell count

Correct answer: C

Rationale: Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. In FVD, there is a loss of fluid without a proportional loss of electrolytes, leading to hemoconcentration. Choices A, B, and D are incorrect. Decreased hematocrit and decreased white blood cell count are not typical findings in fluid volume deficit. An increased white blood cell count is more indicative of infection or inflammation rather than fluid volume deficit.

4. A nurse is planning to administer multiple medications to a client with dysphagia. What action should the nurse take?

• A. Crush medications and mix them with honey
• B. Provide medications through a straw
• C. Place the medications in small amounts of pudding
• D. Offer the medications with a full glass of water

Correct answer: C

Rationale: The correct action for the nurse to take when administering medications to a client with dysphagia is to place the medications in small amounts of pudding. Mixing medications with pudding helps clients with dysphagia swallow them more easily. Choice A (crushing medications and mixing with honey) is not recommended as it may alter the medication properties. Choice B (providing medications through a straw) is not suitable for clients with dysphagia as it can pose a choking hazard. Choice D (offering medications with a full glass of water) may be difficult for clients with dysphagia to swallow and increase the risk of aspiration.

5. 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.

Similar Questions