Nursing Elites

1. The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique?

• A. Remove old dressing using clean gloves. Discard gloves with old dressing
• B. Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area
• C. Apply sterile gauze dressing to wound area
• D. Secure dressing with tape

Correct answer: A

Rationale: The correct order ensures proper aseptic technique and wound care to prevent infection. The first step is to remove the old dressing using clean gloves to prevent contamination. Discarding the gloves with the old dressing helps maintain cleanliness. Choices B, C, and D are incorrect because cleaning the wound, applying a new dressing, and securing it should come after removing the old dressing to maintain asepsis and prevent infection.

2. The client with diabetes mellitus type 1 has a fruity breath odor. What is the priority nursing action?

• A. Evaluate the client’s intake and output
• B. Measure the client’s capillary blood glucose
• C. Consult with the dietitian about the client’s diet
• D. Apply a pulse oximeter to the client’s finger

Correct answer: B

Rationale: Fruity breath odor in a client with diabetes mellitus type 1 can indicate ketoacidosis, a serious complication. Measuring the client’s capillary blood glucose is the priority nursing action in this scenario as it helps diagnose and manage the condition effectively. Evaluating intake and output may be important for overall assessment but not the priority when dealing with a potential emergency like ketoacidosis. Consulting with a dietitian about the client’s diet is important for long-term management but not the immediate priority. Applying a pulse oximeter is not relevant to addressing the fruity breath odor and suspected ketoacidosis.

3. The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure?

• A. When changing the dressing, the tape should be removed slowly to prevent trauma to the skin
• B. To prevent infection, the dressing should be kept dry to avoid excess moisture
• C. The skin incision should be kept moist to promote healing and prevent dryness
• D. The incision should be protected from fecal contamination by an intact dressing

Correct answer: D

Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.

4. The nurse working on a mental health unit is prioritizing nursing care activities due to a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened, and morning medications need to be prepared. Which plan is best for the nurse to implement?

• A. Wake all the clients and instruct them to go to the dining area for medication administration
• B. Explain to the clients that it will be necessary to cooperate until another RN arrives
• C. Ask the PN to administer medications as clients are awakened so both nurses are available
• D. Allow the clients to sleep until a third staff person can assist with unit activities

Correct answer: C

Rationale: The best plan for the nurse to implement is to ask the PN to administer medications as clients are awakened. This approach ensures that medication administration and client care are efficiently managed despite the staffing shortage. Option A is incorrect as it may disrupt the workflow and create unnecessary chaos. Option B is not the best choice as it does not address the immediate need for medication administration. Option D is not ideal as it delays client care until additional staff arrive, potentially compromising patient safety and timely medication administration.

5. A male client with diabetes mellitus takes NPH/regular 70/30 insulin before meals and azithromycin PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of azithromycin an hour before breakfast as instructed. What action should the nurse implement?

• A. Provide a PRN dose of an antacid to take with the azithromycin right after breakfast
• B. Offer to obtain a new breakfast tray in an hour so the client can take the azithromycin
• C. Instruct the client to eat his breakfast and take the azithromycin two hours after eating
• D. Tell the client to skip that day's dose and resume taking the azithromycin the next day

Correct answer: C

Rationale: Azithromycin should ideally be taken on an empty stomach; however, if taken after breakfast, it should not affect its efficacy. Instructing the client to eat his breakfast and take the azithromycin two hours after eating allows for proper absorption without compromising its effectiveness. Providing an antacid with azithromycin is not necessary in this case. Offering a new breakfast tray in an hour or skipping the dose is not the best course of action as it may lead to missed doses and potential effectiveness issues.

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