Nursing Elites

1. The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus ulcer?

• A. Encourage the client to eat foods high in protein
• B. Assess the client for daily range of motion exercises
• C. Teach the family how to perform sterile wound care
• D. Ensure the IV fluids are administered as prescribed

Correct answer: A

Rationale: Encouraging the client to eat foods high in protein is crucial in preventing further development of decubitus ulcers as high protein foods support tissue repair and skin integrity. Adequate protein intake is essential for wound healing. Assessing the client for daily range of motion exercises is important for preventing complications related to immobility, but it may not directly address the prevention of decubitus ulcers. Teaching the family how to perform sterile wound care is significant for wound management but may not be the most effective intervention to prevent further development of decubitus ulcers. Ensuring IV fluids are administered as prescribed is essential for maintaining hydration status but is not the most relevant intervention for preventing decubitus ulcers.

2. During a health screening, a client's blood pressure reads 160/100 mm Hg. What should the nurse recommend?

• A. Schedule a follow-up appointment
• B. Start making immediate dietary changes
• C. Begin an exercise program
• D. All of the above

Correct answer: A

Rationale: A follow-up with a healthcare provider is necessary to assess and manage the newly identified hypertension. While dietary changes and exercise are important for managing high blood pressure, immediate lifestyle modifications without further evaluation by a healthcare provider may not be safe or effective. Option A is the most appropriate initial step to ensure proper assessment and management of the client's blood pressure. Therefore, choices B and C are incorrect in this scenario. Option D is also incorrect because not all options should be implemented without proper medical guidance.

3. The nurse is in charge of a Nursing unit in a long-term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients?

• A. Measure the amount of a client's residual urine after voiding
• B. Cleanse the perineal area of a client with urinary incontinence
• C. Insert a straight catheter to obtain a urine specimen for culture
• D. Provide catheter care for a client with a suprapubic catheter

Correct answer: B

Rationale: The correct answer is B because cleaning the perineal area is a task within the scope of practice for unlicensed assistive personnel (UAPs) and is crucial for preventing infections. Choice A involves a more complex task that requires a healthcare provider's assessment. Choice C involves a sterile procedure that should be performed by licensed staff. Choice D involves specific care for a client with a catheter that exceeds the UAP's scope of practice.

4. The nurse is teaching a client with diabetes about foot care. Which instruction is most important to prevent complications?

• A. Soak feet in warm water daily
• B. Apply moisturizer between the toes
• C. Wear cotton socks
• D. Inspect feet daily for cuts or sores

Correct answer: D

Rationale: The correct answer is D: Inspect feet daily for cuts or sores. Daily foot inspection is crucial for clients with diabetes to detect early signs of injury or infection. Soaking feet in warm water daily (choice A) can lead to skin maceration, making the skin more susceptible to breakdown. Applying moisturizer between the toes (choice B) can increase moisture and the risk of fungal infections. While wearing cotton socks (choice C) is beneficial for diabetic foot care, it is not as crucial as daily foot inspections to prevent complications.

5. The client with newly diagnosed peptic ulcer disease (PUD) is being taught about lifestyle modifications. Which instruction should be included?

• A. Increase the intake of spicy foods
• B. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs)
• C. Drink coffee in moderation
• D. Eat large meals at bedtime

Correct answer: B

Rationale: The correct instruction to include when teaching a client with newly diagnosed PUD about lifestyle modifications is to avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs can exacerbate peptic ulcer disease by causing further irritation of the gastric mucosa. Increasing the intake of spicy foods (choice A) can aggravate the condition by irritating the stomach lining. Drinking coffee (choice C) can stimulate gastric acid secretion, which may worsen the symptoms of PUD. Eating large meals at bedtime (choice D) can also exacerbate PUD by increasing gastric acid production when the body is at rest, potentially leading to discomfort and symptoms.

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