Nursing Elites

1. The clinician is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?

• A. Covering the wound with a dry dressing
• B. Using hydrogen peroxide soaks
• C. Leaving the area open to dry
• D. Applying a hydrocolloid or foam dressing

Correct answer: D

Rationale: Applying a hydrocolloid or foam dressing is the most effective treatment to promote healing for a Stage 2 skin ulcer. These dressings create a moist environment that supports healing and prevents further tissue damage. Option A (covering the wound with a dry dressing) can lead to drying out the wound bed, hindering healing. Option B (using hydrogen peroxide soaks) can be too harsh and may damage the surrounding healthy tissue. Option C (leaving the area open to dry) can delay healing as it does not provide the necessary moist environment for optimal wound healing.

2. A child is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

• A. Administer analgesics to the child on a routine schedule throughout the day and night.
• B. Offer fluids to the child immediately after surgery.
• C. Allow the child to return to solid foods gradually.
• D. Avoid administering any medication until the child is fully awake.

Correct answer: A

Rationale: Administering analgesics to the child on a routine schedule throughout the day and night is crucial for managing postoperative pain effectively and ensuring the child's comfort. Pain management is a priority in the postoperative period to promote healing and prevent complications. Offering fluids to the child immediately after surgery (Choice B) is essential to prevent dehydration, but pain control takes precedence. Allowing the child to return to solid foods gradually (Choice C) is important, but initially, the child may need to start with clear liquids and progress to soft foods post-tonsillectomy. Avoiding administering any medication until the child is fully awake (Choice D) is not advisable because timely pain relief is essential for the child's comfort and recovery.

3. During a dressing change, a healthcare professional observes granulation tissue in a client's wound. Which of the following findings should be documented?

• A. Stringy, white tissue
• B. Translucent, red tissue
• C. Soft, yellow tissue
• D. Thick, black tissue

Correct answer: B

Rationale: Granulation tissue is a hallmark of healing in wounds. It appears as translucent and red, indicating angiogenesis and the formation of new blood vessels in the wound bed. This tissue is vital for wound healing as it provides a scaffold for cell migration and promotes re-epithelialization. Choices A, C, and D do not describe granulation tissue accurately. Stringy, white tissue may suggest fibrin, soft, yellow tissue could indicate slough, and thick, black tissue may imply necrotic tissue, all of which are not synonymous with granulation tissue and do not signify the healing process.

4. A healthcare professional is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the healthcare professional expect?

• A. Decreased calcium
• B. Elevated potassium
• C. Increased sodium
• D. Low hemoglobin

Correct answer: A

Rationale: A positive Chvostek's sign is a clinical indication of low calcium levels, known as hypocalcemia. This sign is elicited by tapping the facial nerve anterior to the ear, resulting in facial muscle twitching. The correct laboratory finding associated with a positive Chvostek's sign is decreased calcium. Elevated potassium (Choice B) is not typically associated with Chvostek's sign but can be seen in conditions like renal failure. Increased sodium (Choice C) is not directly related to Chvostek's sign and is more commonly associated with hypernatremia. Low hemoglobin (Choice D) is not the expected laboratory finding in a client with a positive Chvostek's sign; instead, it suggests anemia, which is unrelated to this clinical manifestation.

5. The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take?

• A. Directly address the child instead of the mother.
• B. Continue asking the mother questions about the child.
• C. Request another nurse to interview the mother now.
• D. Politely ask the mother to look at you when answering.

Correct answer: B

Rationale: In this scenario, the LPN should continue asking the mother questions about the child. The mother's behavior of looking at the floor may be a cultural practice, such as avoiding direct eye contact, which should be respected. By maintaining the conversation with the mother, the nurse acknowledges and respects her communication style, fostering trust and open dialogue. Option A is not the best choice as it may disregard the cultural context and the importance of the mother's input. Option C is unnecessary as the LPN can effectively handle the situation. Option D could be perceived as insensitive and may disrupt the rapport between the nurse and the mother.

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