Nursing Elites

1. Nail and foot care are essential in meeting the basic hygiene needs of clients. Important assessments by the nurse in this area include:

• A. a full-body assessment is not specific to nail and foot care.
• B. the essential lab work of the client is not related to nail and foot assessments.
• C. the nail beds and the tissue surrounding the nails.
• D. foot corns and calluses only neglect other important aspects of nail and foot care.

Correct answer: C

Rationale: The correct answer is to assess the nail beds and the tissue surrounding the nails. This assessment is crucial to identify abnormal discoloration, lesions, paronychia, dryness, breaks in the skin, pressure areas, or any other unusual appearances. Choice A is incorrect as a full-body assessment is broader and not specific to nail and foot care. Choice B is incorrect as lab work is not directly related to nail and foot assessments. Choice D is incorrect as it focuses only on foot corns and calluses, neglecting other important aspects of nail and foot care.

2. Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?

• A. "You will not be allowed to see your family member after the postmortem care is performed."?
• B. "I am not able to assist you, but we can call pastoral care if you need any comfort."?
• C. "Unfortunately, we are not allowed to incorporate any cultural practices in my preparations."?
• D. "I will be ensuring that your family member is properly identified before they are transported."?

Correct answer: D

Rationale: The correct statement when preparing to provide postmortem care to the client's family is to assure them that the family member will be properly identified before transportation. This is crucial in ensuring the correct individual is being handled respectfully. Choices A, B, and C are incorrect as they do not address the essential aspect of ensuring the proper identification of the deceased before transportation. It is important to allow the family to see their loved one after postmortem care and, if possible, incorporate any cultural practices. Providing comfort and support to the family during this difficult time is also essential in delivering holistic care.

3. Why is padding on a restraint helpful?

• A. To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
• B. To help the client feel more secure.
• C. To keep infection and wounds at bay.
• D. To keep restraints in place.

Correct answer: A

Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm. Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm. Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution. Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.

4. Which of the following lab values is associated with a decreased risk of cardiovascular disease?

• A. high HDL cholesterol
• B. low HDL cholesterol
• C. low total cholesterol
• D. low triglycerides

Correct answer: B

Rationale: High HDL cholesterol is associated with a decreased risk of cardiovascular disease because HDL cholesterol is known as 'good' cholesterol. It helps remove other forms of cholesterol, like LDL cholesterol, from the bloodstream, reducing the risk of plaque buildup in the arteries. Low HDL cholesterol (Choice B) is actually a risk factor for cardiovascular disease because it means there is less of the 'good' cholesterol to perform its protective functions. Low total cholesterol (Choice C) and low triglycerides (Choice D) are not necessarily associated with a decreased risk of cardiovascular disease, as the balance and types of cholesterol play a more crucial role in heart health.

5. A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?

• A. Notify the physician.
• B. Clamp the chest tube.
• C. Replace the system.
• D. Document the finding

Correct answer: D

Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse. Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.

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