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. The PN notes that a UAP is ambulating a male client who had a stroke and has right-sided weakness. The UAP is walking on the client's left side. Which action should the PN take?

• A. Instruct the UAP to walk on the client's affected side
• B. Take over the ambulation and provide guidance to the UAP immediately
• C. Provide the client with an assistive device, such as a cane or walker
• D. Tell the UAP to take the client back to his room

Correct answer: A

Rationale: The correct action for the PN to take is to instruct the UAP to walk on the client’s affected side. This is essential to provide the necessary support and prevent falls, especially when the client has weakness on one side due to a stroke. Walking on the affected side helps provide stability and assistance to the weaker side. Choice B is incorrect because it would be more appropriate for the PN to provide immediate guidance and correct the UAP's positioning rather than taking over the task completely. Choice C is incorrect because while assistive devices may be beneficial, the immediate concern is the UAP's positioning during ambulation, not providing the client with an assistive device. Choice D is incorrect as there is no indication to return the client to his room unless it is necessary for his safety or well-being.

3. A client on bedrest refuses to wear the prescribed pneumatic compression devices after surgery. Which action should the PN implement in response to the client's refusal?

• A. Emphasize the importance of active foot flexion
• B. Check the surgical dressing
• C. Complete an incident report
• D. Explain the use of an incentive spirometer every 2 hours

Correct answer: A

Rationale: The correct action for the PN to implement when a client refuses pneumatic compression devices is to emphasize the importance of active foot flexion. Active foot flexion exercises can help prevent deep vein thrombosis (DVT) in clients who are not using the compression devices. Encouraging some form of circulation-promoting activity is crucial to reduce the risks associated with immobility. Checking the surgical dressing (Choice B) is important but not the immediate action to address the refusal of compression devices. Completing an incident report (Choice C) is not necessary in this situation as the client's refusal is not an incident. Explaining the use of an incentive spirometer (Choice D) is not directly related to addressing the refusal of compression devices for DVT prevention.

4. When administering IV fluids to a client with a history of congestive heart failure (CHF), what is the nurse's primary concern?

• A. Monitoring for signs of fluid overload.
• B. Ensuring the client receives enough fluids to prevent dehydration.
• C. Preventing electrolyte imbalances.
• D. Maintaining the prescribed rate of fluid administration.

Correct answer: A

Rationale: The primary concern when administering IV fluids to a client with a history of congestive heart failure (CHF) is monitoring for signs of fluid overload. Clients with CHF are particularly vulnerable to fluid overload, which can exacerbate their condition. Signs of fluid overload include edema and difficulty breathing. Therefore, the nurse must closely monitor these signs to prevent worsening of the client's condition. Choices B, C, and D are incorrect because while ensuring hydration, preventing electrolyte imbalances, and maintaining the prescribed rate of fluid administration are important, they are secondary concerns compared to the critical task of monitoring for fluid overload in a client with CHF.

5. An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units in the morning. Which finding should the PN document as evidence that the amount of insulin is inadequate?

• A. States that her feet are constantly cold and feel numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dL
• D. Reports nausea in the morning but can still eat breakfast

Correct answer: C

Rationale: The correct answer is C. High evening glucose levels indicate that the morning dose of NPH insulin may be insufficient to control blood sugar throughout the day. Choice A is incorrect as cold and numb feet are more indicative of a circulation issue rather than an insulin inadequacy. Choice B suggests a wound infection rather than inadequate insulin. Choice D, nausea in the morning, may be due to other causes and does not necessarily indicate inadequate insulin dosage.

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