Nursing Elites

1. What is the initial step a nurse should take when irrigating a wound?

• A. Wear sterile gloves while removing the old dressing
• B. Cleanse the wound from the center outward
• C. Apply a warm compress to the wound
• D. Use a 20 mL syringe to irrigate the wound

Correct answer: B

Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.

2. A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?

• A. Use a bed exit alarm to notify staff of attempts to leave the bed
• B. Raise all four side rails for safety
• C. Encourage frequent ambulation with assistance
• D. Use restraints to prevent the client from getting out of bed

Correct answer: A

Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.

3. Which of the following is an expected side effect of furosemide?

• A. Bradycardia
• B. Hypokalemia
• C. Increased blood pressure
• D. Increased urine output

Correct answer: B

Rationale: The correct answer is B, Hypokalemia. Furosemide is a loop diuretic that works by increasing the excretion of water and electrolytes, including potassium, leading to hypokalemia. Choice A, Bradycardia, is incorrect because furosemide does not typically cause a decrease in heart rate. Choice C, Increased blood pressure, is incorrect as furosemide is actually used to lower blood pressure by reducing fluid volume. Choice D, Increased urine output, is a common effect of furosemide due to its diuretic action but is not an adverse side effect.

4. What action should the nurse take for a client struggling to void after having an indwelling catheter removed?

• A. Assess for bladder distention after 2 hours
• B. Encourage the client to try urinating in a sitting position
• C. Pour warm water over the client's perineum
• D. Restrict the client's fluid intake

Correct answer: C

Rationale: The correct action for the nurse to take is to pour warm water over the client's perineum. This intervention helps stimulate urination after catheter removal by providing warmth and promoting relaxation of the muscles. Assessing for bladder distention after 2 hours (Choice A) is not the initial intervention to facilitate voiding. Encouraging the client to try urinating in a sitting position (Choice B) may be uncomfortable if the client is struggling to void. Restricting the client's fluid intake (Choice D) is not appropriate as it can further exacerbate the issue by concentrating the urine.

5. A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which of the following information should the nurse include?

• A. Frequent hand washing prevents infection
• B. Prolonged use of corticosteroids increases infection risk
• C. Limit patient interaction to reduce infection spread
• D. Restrict client movement to prevent contamination

Correct answer: B

Rationale: The correct answer is B because prolonged use of corticosteroids is a known risk factor for infections. Choice A is incorrect because frequent hand washing actually helps prevent infections. Choice C is incorrect as patient interaction is essential in healthcare but should be done following proper infection control measures. Choice D is also incorrect as restricting client movement is not a standard practice to prevent contamination.

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