Nursing Elites

1. In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will:

• A. Be at an increased susceptibility for infection
• B. Have a wound that heals more slowly
• C. Experience more pain during the healing process
• D. Require more frequent dressing changes

Correct answer: A

Rationale: Wounds healing by secondary intention involve the gradual filling of the wound with granulation tissue, leading to a higher risk of infection due to prolonged exposure. This makes choice A the correct answer. Choices B and C are incorrect because wounds healing by secondary intention take longer to heal and often result in more pain compared to wounds healing by primary intention. Choice D is also incorrect as wounds healing by secondary intention usually require more frequent dressing changes to prevent infection and promote healing.

2. A healthcare professional is preparing to perform a sterile dressing change for a client. Which of the following actions should the healthcare professional plan to take?

• A. Don sterile gloves after opening sterile dressing supplies
• B. Set up the sterile field at waist level
• C. Consider the entire border of the sterile field as contaminated
• D. Place the cap of a sterile solution inside the sterile field

Correct answer: B

Rationale: Setting up the sterile field at waist level is crucial to maintaining its sterility during a dressing change. Choice A is incorrect because sterile gloves should be worn after opening sterile dressing supplies to prevent contamination. Choice C is incorrect as the entire border of the sterile field should be considered contaminated to maintain sterility. Choice D is incorrect because the cap of a sterile solution should never be placed inside the sterile field to prevent contamination.

3. A client who is lactating is being taught about taking medications by a nurse. Which of the following actions should the nurse recommend to minimize the entry of medication into breast milk?

• A. Drink 8 oz of water with each dose of medication.
• B. Use medications that have a short half-life.
• C. Take each dose right after breastfeeding.
• D. Pump breast milk and discard it prior to feeding the newborn.

Correct answer: C

Rationale: Taking medications immediately after breastfeeding helps minimize the amount of medication that enters breast milk. By doing so, there is a longer interval between the medication intake and the next breastfeeding session, reducing the concentration of the medication in breast milk. Options A and B are incorrect as drinking water with medication or using medications with a short half-life do not directly minimize the entry of medication into breast milk. Option D is unnecessary and wasteful as pumping and discarding breast milk before feeding is not as effective as timing medication intake with breastfeeding to reduce medication transfer into breast milk.

4. While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take?

• A. Force oral fluids
• B. Request a nutrition consult
• C. Initiate contact precautions
• D. Limit visitors to immediate family only

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to initiate contact precautions. MRSA (Methicillin-resistant Staphylococcus aureus) is a highly contagious bacterium that spreads through direct contact. Contact precautions involve wearing gloves and gowns to prevent the spread of infection to other patients or healthcare workers. Force-feeding oral fluids, requesting a nutrition consult, or limiting visitors to immediate family only are not the most appropriate actions in this scenario. These actions do not directly address the need to prevent the spread of MRSA, which is crucial in a healthcare setting.

5. When preparing to lift and reposition a patient, which action should the nurse take first?

• A. Assess weight to determine assistance needs.
• B. Position a drawsheet under the patient.
• C. Delegate the task to a nursing assistive personnel.
• D. Attempt to manually lift the patient alone before asking for assistance.

Correct answer: A

Rationale: The first action the nurse should take when preparing to lift and reposition a patient is to assess the patient's weight to determine the assistance needed. This step is crucial for the safety of both the patient and the nurse. Positioning a drawsheet under the patient (Choice B) is important for the comfort and safety during the repositioning process but should come after assessing the weight and assistance requirements. Delegating the task to a nursing assistive personnel (Choice C) can be considered once the assessment is complete and additional help is needed. Attempting to manually lift the patient alone before asking for assistance (Choice D) is unsafe and should never be done without first assessing the weight and determining the need for help.

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