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 client requires rectal temperature monitoring, and a nurse has a thermometer with a long, slender tip at the bedside. What is the appropriate action for the nurse to take?

• A. Obtain a thermometer with a short, blunt insertion end
• B. Use the available thermometer as is
• C. Request a new thermometer
• D. Measure the temperature orally instead

Correct answer: A

Rationale: When monitoring rectal temperature, it is crucial to use a thermometer with a short, blunt insertion end to prevent injury and ensure accurate readings. Using a thermometer with a long, slender tip can pose a risk of perforation or discomfort for the client. Therefore, the appropriate action for the nurse to take is to obtain a thermometer with a short, blunt insertion end. Using the available thermometer as is would not address the safety concerns. Requesting a new thermometer is unnecessary when a suitable one is available by just obtaining it. Measuring the temperature orally instead would not provide the required rectal temperature monitoring.

3. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client’s record first?

• A. Assessment
• B. History of present illness
• C. Plan of care
• D. Admission date and time

Correct answer: D

Rationale: When admitting a client to a medical-surgical unit, documenting the admission date and time is crucial as it establishes the timeline for the client's care. This information ensures accurate tracking of interventions and facilitates communication among the healthcare team. While assessment, history of present illness, and plan of care are important components of the admission process, documenting the admission date and time takes priority to establish a baseline for care delivery. Without the admission date and time, the continuity of care and coordination among healthcare providers may be compromised.

4. The LPN/LVN mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?

• A. 31 gtt/min.
• B. 62 gtt/min.
• C. 93 gtt/min.
• D. 124 gtt/min.

Correct answer: D

Rationale: To calculate the drops per minute for the client, first, convert the weight from pounds to kilograms by dividing 182 by 2.2, which equals 82.72 kg. Then, calculate the dose in mcg/min by multiplying the weight in kg by the rate (82.72 kg * 5 mcg/kg/min = 413.6 mcg/min). Next, convert 50 mg to mcg (50 mg * 1000 = 50,000 mcg). Divide the total mcg (50,000 mcg) by the dose per minute (413.6 mcg/min) to get approximately 121 gtt/min. However, since the drip factor is 60 gtt/ml, the correct answer is 124 gtt/min, ensuring the accurate administration rate of the medication. Therefore, choice 'D' is the correct answer. Choices 'A', 'B', and 'C' are incorrect as they do not accurately reflect the calculated drops per minute based on the given information.

5. What action should be taken to maintain the patency of a peripherally inserted central catheter (PICC)?

• A. Flush the catheter with heparin solution daily.
• B. Change the dressing at the insertion site daily.
• C. Use sterile technique when changing the dressing.
• D. Keep the insertion site dry at all times.

Correct answer: C

Rationale: The correct answer is to use sterile technique when changing the dressing. This practice is essential for preventing infections that can compromise the patency of the PICC line. While flushing the catheter with heparin solution helps prevent clot formation, it does not directly maintain patency. Changing the dressing daily is important for hygiene but does not have a direct impact on catheter patency. Keeping the insertion site dry is crucial to prevent infections but does not specifically address patency maintenance.

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