Nursing Elites

1. Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?

• A. Use sterile technique when applying the compresses.
• B. Leave the compresses on the area continuously, pouring warm solution on the area when it cools down.
• C. Alternate warm compresses with cold compresses.
• D. Apply a wet dressing and cover it with a dry dressing.

Correct answer: A

Rationale: Using sterile technique when applying the compresses is crucial to prevent infection and promote wound healing. Ensuring a clean environment during wound care reduces the risk of introducing pathogens that can lead to complications. Proper infection control measures play a significant role in the healing process of open wounds. Choice B is incorrect because leaving the compresses on continuously can lead to skin damage or thermal injury. Choice C is incorrect as alternating warm compresses with cold compresses is not appropriate for an open wound. Choice D is incorrect as applying a wet dressing without following specific orders can be detrimental to wound healing.

2. A client is to receive cimetidine (Tagamet) 300 mg q6h IVP. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?

• A. 75 ml/hr
• B. 150 ml/hr
• C. 225 ml/hr
• D. 300 ml/hr

Correct answer: B

Rationale: To calculate the infusion rate, set up a ratio proportion problem: 50 ml/20 min = x ml/60 min. Cross multiply to solve: 50 × 60 / 20 = 150 ml/hr. Therefore, the infusion pump should be set to deliver the secondary infusion at a rate of 150 ml/hr. Option A, 75 ml/hr, is incorrect because it does not account for the correct calculation. Option C, 225 ml/hr, is incorrect as it is too high a rate based on the calculation. Option D, 300 ml/hr, is also incorrect as it does not align with the correct calculation for the infusion rate.

3. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regimen. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?

• A. Surgery removes the disk and is the only treatment that can totally resolve the pain
• B. The medication regimen you previously used should be re-evaluated for dose adjustment
• C. Massage and hot pack treatments are less invasive and can provide temporary relief
• D. Acupuncture is a complementary therapy that is often effective for management of pain

Correct answer: D

Rationale: Acknowledging the effectiveness of acupuncture is important, as the client has reported its success in managing her pain previously.

4. The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?

• A. Increase intake of foods high in potassium.
• B. Avoid foods high in sodium.
• C. Limit fluid intake to 1.5 liters per day.
• D. Increase intake of foods high in vitamin K.

Correct answer: B

Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely as it can affect heart rhythm. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management and is more relevant for clients on anticoagulants to manage blood clotting.

5. A client has a nursing diagnosis of 'Spiritual distress related to a loss of hope, secondary to impending death.' What intervention is best for the nurse to implement when caring for this client?

• A. Help the client accept the final stage of life.
• B. Assist and support the client in establishing short-term goals.
• C. Encourage the client to make future plans, even if they are unrealistic.
• D. Instruct the client's family to focus on positive aspects of the client's life.

Correct answer: B

Rationale: When a client is experiencing spiritual distress due to a loss of hope related to impending death, it is crucial for the nurse to assist and support the client in establishing short-term goals. This approach helps the client maintain hope and a sense of purpose, as achieving immediate goals can provide a sense of accomplishment and meaning. While acceptance of the final stage of life is important, helping the client set short-term goals is a more immediate and effective intervention in addressing spiritual distress. Encouraging the client to make future plans, especially if they are unrealistic, may not be beneficial as it could lead to further distress if those plans are unattainable. Instructing the client's family to focus on positive aspects of the client's life, though supportive, does not directly address the client's spiritual distress and loss of hope.

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