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 preparing a client for discharge who has a prescription for enoxaparin (Lovenox) self-administration. What information is most important for the nurse to provide the client about this medication?

• A. Self-administration techniques for subcutaneous injection
• B. Avoiding foods high in vitamin K
• C. Signs of bleeding to report to the healthcare provider
• D. Proper disposal of used syringes

Correct answer: A

Rationale: Teaching the client about self-administration techniques for subcutaneous injection is crucial for safe and effective use of enoxaparin. Option A is the correct answer as it directly addresses the client's need to know how to properly administer the medication. Options B, C, and D are important aspects of care but are not the most critical information needed for the client's self-administration of enoxaparin.

3. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

• A. Prepare for immediate cesarean birth
• B. Turn off the oxytocin (Pitocin) infusion
• C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
• D. Apply an internal fetal monitoring device and continue to monitor carefully

Correct answer: B

Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.

4. The healthcare provider prescribes a diet high in vitamin C for a client with a leg wound. Which food should the nurse encourage the client to eat?

• A. Bananas and pineapple
• B. Cottage cheese and crackers
• C. Peanut butter and jelly
• D. Tomato and lettuce salad

Correct answer: D

Rationale: Tomatoes and lettuce are high in vitamin C, making them suitable choices for a diet prescribed for wound healing. Bananas and pineapple (Choice A) are not particularly high in vitamin C compared to tomatoes and lettuce. Cottage cheese and crackers (Choice B) as well as peanut butter and jelly (Choice C) do not provide significant amounts of vitamin C, which is essential for wound healing.

5. A client with chronic renal failure is being discharged with a prescription for erythropoietin (Epogen). Which statement indicates that the client understands the action of this medication?

• A. It helps my body make red blood cells
• B. It helps prevent infections
• C. It helps my kidneys excrete excess fluid
• D. It helps me breathe easier

Correct answer: A

Rationale: The correct answer is A: 'It helps my body make red blood cells.' Erythropoietin is a medication that stimulates the production of red blood cells in the body. Clients with chronic renal failure often develop anemia due to decreased erythropoietin production by the kidneys. This medication helps address that issue by increasing red blood cell production. Choices B, C, and D are incorrect because erythropoietin does not prevent infections, help kidneys excrete excess fluid, or assist with breathing; its primary action is to boost red blood cell production.

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