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 nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

• A. Dissolve each medication in 5 mL of sterile water.
• B. Draw up each medication separately in the syringe.
• C. Push the syringe plunger gently if feeling resistance.
• D. Flush the tube with 15 mL of sterile water.

Correct answer: D

Rationale: The correct action the nurse should take when administering multiple medications to a client with an enteral feeding tube is to flush the tube with 15-30 mL of sterile water before and between medications, and 30-60 mL after the last medication. This helps prevent clogging and ensures each medication is delivered effectively. Choice A is incorrect as medications should not be dissolved in water for administration through an enteral feeding tube. Choice B is incorrect because each medication should be drawn up and administered separately to prevent any potential interactions. Choice C is incorrect as resistance while pushing the plunger may indicate a problem that needs to be addressed before continuing with the administration.

3. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?

• A. 'All of this equipment can be frightening.'
• B. 'The equipment is necessary to monitor your condition.'
• C. 'You should try to ignore the equipment.'
• D. 'Try to relax; the equipment is not harmful.'

Correct answer: A

Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.

4. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?

• A. “I will determine the most important client problems that we should address.”
• B. “I will review the past medical history on the client’s record to gather more information.”
• C. “I will carry out the new prescriptions from the provider.”
• D. “I will ask the client if their nausea has resolved.”

Correct answer: A

Rationale: In the nursing process, the planning step involves determining priorities and goals based on the identified problems. Choice A is correct as it reflects the nurse's role in identifying the most important client problems to address, which aligns with the planning phase. Choices B, C, and D are incorrect. Choice B involves data collection, which is a part of the assessment phase, not planning. Choice C pertains to the implementation of care, which occurs after the planning phase. Choice D involves evaluation of a specific intervention, not planning.

5. A healthcare provider has inserted an indwelling catheter for a male patient. Where should the healthcare provider tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction?

• A. Lower abdomen
• B. Upper thigh
• C. Penoscrotal junction
• D. Mid-abdomen

Correct answer: A

Rationale: Taping the catheter to the lower abdomen is the correct placement to prevent pressure on the urethra at the penoscrotal junction. Securing the catheter at the lower abdomen helps in reducing discomfort and minimizes the risk of trauma to the urethra. Placing the catheter on the upper thigh or penoscrotal junction can lead to tension on the catheter and potential discomfort for the patient. Taping the catheter to the mid-abdomen is not recommended as it does not provide the necessary support to prevent pressure on the urethra at the penoscrotal junction.

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