Nursing Elites

1. What are the principles of aseptic technique in wound care?

• A. Use sterile gloves and a clean dressing
• B. Apply a clean dressing using sterile scissors
• C. Wash hands thoroughly before applying the dressing
• D. Use a clean glove and avoid contact with the wound

Correct answer: A

Rationale: The correct answer is A: 'Use sterile gloves and a clean dressing.' Aseptic technique in wound care requires the use of sterile gloves to prevent infection. Choice B is incorrect as the method of application does not primarily focus on maintaining asepsis. Choice C, while important for infection control, is not specific to aseptic technique in wound care. Choice D is incorrect because using a single clean glove does not ensure the level of sterility needed for aseptic wound care.

2. A client with heart failure is receiving furosemide. Which of the following assessment findings indicates that the medication is effective?

• A. Elevated blood pressure.
• B. Absence of adventitious breath sounds.
• C. Weight gain of 1.4 kg (3 lb) in 24 hr.
• D. Decreased urine output.

Correct answer: B

Rationale: The absence of adventitious breath sounds indicates that furosemide is effective in managing heart failure. Adventitious breath sounds such as crackles indicate fluid accumulation in the lungs, a common complication of heart failure. Therefore, the absence of these abnormal sounds suggests that furosemide is effectively reducing fluid overload. Elevated blood pressure (choice A) is not a desired outcome in heart failure management. Weight gain (choice C) and decreased urine output (choice D) are signs of fluid retention and ineffective diuresis, indicating that furosemide is not working effectively.

3. Which intervention is most important for a client with chronic heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Limit sodium intake to reduce fluid retention
• D. Restrict daily activity to prevent fatigue

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with chronic heart failure. Monitoring weight helps in detecting fluid retention or fluid loss, which is crucial in managing heart failure. Encouraging fluid intake to prevent dehydration (choice A) may worsen fluid overload in heart failure patients. Limiting sodium intake (choice C) is essential but not the most important intervention compared to monitoring weight. Restricting daily activity (choice D) is not recommended as it is important for clients with heart failure to engage in appropriate levels of physical activity to maintain their overall health.

4. A nurse is caring for a client post-op with a chest tube. What should the nurse check for regularly?

• A. Ensure the chest tube is periodically clamped
• B. Check for air leaks in the tubing
• C. Keep the client in a prone position for chest drainage
• D. Administer diuretics to prevent fluid buildup

Correct answer: B

Rationale: The correct answer is to check for air leaks in the tubing. Air leaks can compromise the function of the chest tube, leading to inadequate drainage and potentially causing complications for the client. Clamping the chest tube periodically is incorrect as it could lead to a buildup of fluid or air in the pleural space. Keeping the client in a prone position is not necessary for chest drainage, as the positioning may vary depending on the specific situation. Administering diuretics may not be directly related to monitoring the chest tube for proper function and is not a routine intervention for chest tube management post-op.

5. How should a healthcare professional manage a patient with suspected myocardial infarction (MI)?

• A. Administer oxygen and call for emergency help
• B. Monitor vital signs and provide pain relief
• C. Provide nitroglycerin and thrombolytics
• D. Administer diuretics and provide a high-protein diet

Correct answer: A

Rationale: Administering oxygen and seeking emergency help are crucial initial steps in managing a patient with suspected myocardial infarction (MI). Oxygen helps to improve oxygenation to the heart muscle, reducing its workload and preventing further damage. Calling for emergency help ensures timely access to advanced medical care, including interventions like thrombolytics. Monitoring vital signs and providing pain relief are important but secondary to the immediate need for oxygen and emergency assistance. Providing nitroglycerin and thrombolytics should be done under medical supervision and following appropriate protocols, not as the first step. Administering diuretics and altering the patient's diet are not indicated in the acute management of MI.

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