Nursing Elites

1. What are the nursing interventions for a patient with a pressure ulcer?

• A. Clean the wound and apply a hydrocolloid dressing
• B. Provide a high-protein diet and ensure bed rest
• C. Monitor for signs of infection and provide antibiotics
• D. Provide a low-sodium diet and monitor for fluid retention

Correct answer: A

Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.

2. A client with a tracheostomy is exhibiting signs of respiratory distress. What is the first action the nurse should take?

• A. Increase the suction setting on the ventilator
• B. Suction the tracheostomy
• C. Notify the physician immediately
• D. Encourage deep breathing exercises

Correct answer: B

Rationale: The correct first action for a client with a tracheostomy exhibiting signs of respiratory distress is to suction the tracheostomy. This helps clear the airway and improve breathing. Increasing the suction setting on the ventilator is not appropriate as the issue may be related to secretions that need to be directly removed. Notifying the physician should come after providing immediate nursing interventions. Encouraging deep breathing exercises is not suitable when the client is in respiratory distress and needs prompt intervention.

3. A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take?

• A. Provide anticipatory guidance classes to parents through public schools.
• B. Have a nurse from outside the community provide health lectures at the county hospital.
• C. Encourage rural residents to focus health spending on tertiary health interventions.
• D. Launch a media campaign to increase awareness about industrial pollution.

Correct answer: A

Rationale: Providing anticipatory guidance classes to parents through public schools is the most appropriate action for the public health nurse in a rural area. This approach allows the nurse to address early prevention strategies, which are crucial in promoting health in rural populations. Choice B is incorrect because having a nurse from outside the community may not fully understand the local needs and dynamics. Choice C is wrong as focusing health spending on tertiary interventions is not cost-effective or preventive. Choice D is also incorrect because while increasing awareness about industrial pollution is important, it may not directly address the health needs of the local rural population.

4. What is the first step in preparing a blood transfusion?

• A. Administer the blood via IV push
• B. Verify the client's blood type before starting the transfusion
• C. Warm the blood to body temperature before administration
• D. Administer diuretics to prevent fluid overload

Correct answer: B

Rationale: The correct first step in preparing a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to ensure compatibility and prevent adverse reactions. Administering the blood via IV push (Choice A) is incorrect as it skips the essential step of verifying the blood type. Warming the blood to body temperature (Choice C) is important but comes after verifying the blood type. Administering diuretics (Choice D) is not part of the preparation process for a blood transfusion.

5. What is the main symptom of left-sided heart failure?

• A. Shortness of breath
• B. Edema
• C. Increased heart rate
• D. Decreased urine output

Correct answer: A

Rationale: Shortness of breath is the main symptom of left-sided heart failure because it results from pulmonary congestion due to fluid buildup in the lungs. Edema, increased heart rate, and decreased urine output are associated with right-sided heart failure rather than left-sided heart failure.

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