Nursing Elites

1. The nurse is preparing to provide wound care for a client. Which step should be done first?

• A. Don procedural gloves
• B. Remove the dressing
• C. Apply prescribed medications to the wound
• D. Don a pair of sterile gloves

Correct answer: A

Rationale: The correct answer is to don procedural gloves first. Donning procedural gloves is essential to protect the nurse from contaminants while removing the old dressing. This step helps maintain aseptic technique and prevents the transfer of microorganisms. Removing the dressing (choice B) should follow after wearing gloves to prevent the spread of pathogens. Applying prescribed medications (choice C) should be done after the wound is cleaned and dressed. Donning a pair of sterile gloves (choice D) is not necessary for initial wound care; procedural gloves are sufficient for standard wound care.

2. A nurse is completing a focused assessment of an older adult's skin. The nurse notes a crusted 0.7 cm lesion on the client's forehead. Which action should the nurse take in response to this finding?

• A. Report the finding to the healthcare provider
• B. Place a clear occlusive dressing over the site
• C. Apply a warm compress to remove the crusted area
• D. Explain that this is a normal skin change with aging

Correct answer: A

Rationale: A crusted lesion, especially in an older adult, could be indicative of skin cancer or another serious condition. Therefore, reporting this finding to the healthcare provider is crucial for further evaluation and appropriate management. Placing an occlusive dressing (Choice B) could prevent proper assessment and treatment. Applying a warm compress (Choice C) may not be suitable for a suspicious skin lesion as it could worsen the condition. Explaining it as a normal skin change (Choice D) without proper evaluation can delay necessary interventions and potentially harm the patient.

3. Based on the computer documentation in the EMR, which action should the PN implement?

• A. Give the rubella vaccine subcutaneously
• B. Observe the mother breastfeeding her infant
• C. Call the nursery for the infant's blood type results
• D. Administer hydrocodone/acetaminophen one tablet for pain

Correct answer: A

Rationale: The rubella vaccine is crucial for preventing rubella infection, which can cause severe congenital disabilities if contracted during pregnancy. Administering the vaccine subcutaneously is the correct action based on EMR documentation. Observing breastfeeding, calling the nursery for blood type results, and administering pain medication are not indicated by the EMR documentation and are not relevant to the situation described in the question.

4. An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the PN?

• A. No bowel movement for two days
• B. Mother assists child in changing positions
• C. Weights are touching the foot of the bed
• D. Child is able to move the toes freely when tickled

Correct answer: C

Rationale: In 90-90 traction, it is crucial to ensure that the weights are not touching the foot of the bed as this can disrupt the effective application of traction. This interference can hinder the proper alignment of the fractured femur and impede the healing process. Therefore, this finding requires immediate action to prevent complications. Choices A, B, and D are not directly related to the proper application of traction and do not pose a risk to the patient's treatment or well-being. No bowel movement for two days may indicate constipation but does not directly relate to the traction. Mother assisting the child in changing positions is a supportive action. The child being able to move the toes freely when tickled indicates neurological function, which is a positive sign.

5. An older postoperative client has the nursing diagnosis 'impaired mobility related to fear of falling.' Which desired outcome best directs the PN's actions for the client?

• A. The client will ambulate with assistance every 4 hours
• B. The physical therapist will instruct the client in the use of a walker
• C. The client will use self-affirmation statements to decrease fear
• D. The PN will place a gait belt on the client prior to ambulation

Correct answer: C

Rationale: The correct answer is C. Using self-affirmation statements helps the client reduce fear and regain confidence in mobility, which is essential for improving impaired mobility. Choice A focuses more on the frequency of ambulation rather than addressing the fear of falling. Choice B involves the physical therapist and the use of a walker, which may not directly address the client's fear. Choice D is a safety measure but does not specifically target the client's fear of falling.

Similar Questions