Nursing Elites

1. The nurse is planning care for a client with a stage III pressure ulcer. Which intervention is most important for the nurse to include in the plan of care?

• A. Reposition the client every 2 hours
• B. Cleanse the ulcer with normal saline
• C. Apply a moisture-retentive dressing
• D. Measure the ulcer's depth and diameter

Correct answer: D

Rationale: The correct answer is to measure the ulcer's depth and diameter. This intervention is crucial as it helps monitor healing progress and evaluate the effectiveness of the care plan. Measuring the ulcer provides valuable information about the wound's improvement or deterioration. Repositioning the client every 2 hours (Choice A) is important for preventing further skin breakdown but may not be the priority in this case. Cleansing the ulcer with normal saline (Choice B) is essential for wound care but not the most crucial intervention at this stage. Applying a moisture-retentive dressing (Choice C) can promote healing, but assessing the ulcer's dimensions is more critical for monitoring progress.

2. The nurse is performing an admission assessment of an older client who has difficulty swallowing and has a history of aspiration pneumonia. Which action should the nurse implement first?

• A. Obtain a speech therapy consult
• B. Elevate the head of the bed
• C. Check the client's lung sounds
• D. Implement aspiration precautions

Correct answer: B

Rationale: The correct action for the nurse to implement first is to elevate the head of the bed. Elevating the head of the bed helps prevent aspiration in clients with swallowing difficulties by reducing the risk of food or fluids entering the airway. While obtaining a speech therapy consult (Choice A) is important, the immediate priority is to ensure the client's safety by positioning them properly. Checking the client's lung sounds (Choice C) and implementing aspiration precautions (Choice D) are also essential steps but should follow the immediate intervention of elevating the head of the bed to prevent aspiration.

3. A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?

• A. It dissolves blood clots
• B. It prevents the blood from clotting
• C. It thins the blood
• D. It decreases the risk of infection

Correct answer: B

Rationale: The correct answer is B: 'It prevents the blood from clotting.' Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver, thereby preventing the formation of blood clots. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones from forming. Choice C is partially correct but not as specific as choice B in explaining how warfarin works. Choice D is unrelated to the mechanism of action of warfarin and is incorrect.

4. The nurse is planning care for a client who is receiving radiation therapy for breast cancer. Which intervention is most important for the nurse to include?

• A. Encourage the client to use sunscreen
• B. Apply lotion to the radiated area
• C. Keep the area dry and clean
• D. Encourage the client to exercise the arm

Correct answer: C

Rationale: Keeping the radiated area dry and clean is crucial to prevent skin irritation and infection. Radiation therapy can cause skin changes, making it susceptible to irritation and infection. Using sunscreen (Choice A) is not usually recommended on the radiated area as it can further irritate the skin. Applying lotion (Choice B) may not be suitable as it can trap moisture and cause skin breakdown. While encouraging exercise (Choice D) is important, keeping the area dry and clean takes precedence to prevent complications during radiation therapy.

5. A client who had a cerebral vascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?

• A. Risk for impaired tissue integrity related to impaired physical mobility
• B. Impaired skin integrity related to altered circulation and pressure
• C. Ineffective tissue perfusion related to inability to move self in bed
• D. Impaired physical mobility related to the left side paralysis

Correct answer: B

Rationale: The correct nursing diagnosis for this client is 'Impaired skin integrity related to altered circulation and pressure.' The client's Stage II pressure ulcer on the left hip is a clear indication of impaired skin integrity resulting from altered circulation and pressure due to immobility. Choice A is incorrect because the client already has a pressure ulcer, indicating an actual impairment rather than a risk. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this case. Choice D is incorrect as it focuses solely on the paralysis and not the actual skin integrity issue.

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