Nursing Elites

1. What is the most important action when providing wound care to a client with a pressure ulcer?

• A. Apply a dry, sterile dressing to the wound
• B. Cleanse the wound with normal saline
• C. Perform a wound culture before applying ointment
• D. Cover the wound with a wet-to-dry dressing

Correct answer: C

Rationale: Performing a wound culture before applying ointment is crucial when providing wound care to a client with a pressure ulcer. This action helps identify any underlying infections, allowing healthcare providers to select the most appropriate treatment. Options A, B, and D are not as critical as performing a wound culture, as they focus on wound dressing and cleansing rather than identifying potential infections.

2. A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first?

• A. When did your pain start?
• B. How severe is your pain?
• C. What makes your pain worse?
• D. Where is your pain located?

Correct answer: D

Rationale: The nurse should first ask the client where the pain is located because identifying the location of the pain is crucial in determining the cause and appropriate treatment. This information helps in further assessment and diagnosis. Asking when the pain started (Choice A) may be important but determining the location provides more immediate insights. Inquiring about the severity of pain (Choice B) and what worsens it (Choice C) are also important but come after identifying the location to provide a comprehensive understanding of the client's condition.

3. A client with IV fluids has developed redness and warmth at the IV site. What is the next step the nurse should take?

• A. Apply a cold compress to the IV site
• B. Discontinue the IV and notify the healthcare provider
• C. Monitor the IV site for signs of infection
• D. Increase the IV flow rate to improve circulation

Correct answer: B

Rationale: When a client develops redness and warmth at the IV site, it is indicative of phlebitis, which is inflammation of the vein. The next step for the nurse should be to discontinue the IV and notify the healthcare provider. Applying a cold compress may provide temporary relief but does not address the underlying issue. Monitoring for infection is important, but in this case, the presence of redness and warmth suggests phlebitis, not infection. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

4. A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique?

• A. Putting a glove on the dominant hand first
• B. Removing gloves and putting on a sterile gown first
• C. Putting sterile gloves last
• D. Applying gloves without touching outer surfaces

Correct answer: A

Rationale: The correct answer is A. Putting the glove on the dominant hand first is a key step in maintaining sterile technique as it reduces the risk of contamination. By covering the dominant hand first, the nurse minimizes the risk of contaminating the other hand during the glove application process. Choices B, C, and D are incorrect. Choice B introduces the concept of a sterile gown, which is not relevant to the question about applying sterile gloves. Choice C is incorrect as putting sterile gloves last does not follow the correct sequence of steps in maintaining sterility. Choice D, while important, is not as critical as covering the dominant hand first when applying sterile gloves.

5. What are the signs and symptoms of Cushing's syndrome, and how should they be managed?

• A. Weight gain, moon face; administer corticosteroids
• B. Hirsutism and thin extremities; manage with diuretics
• C. Purple striae, muscle weakness; provide dietary counseling
• D. Hypertension and bruising; manage with fluid restriction

Correct answer: A

Rationale: The correct signs and symptoms of Cushing's syndrome are weight gain and a moon face. Corticosteroids are used to manage Cushing's syndrome by reducing the overproduction of cortisol. Choice B is incorrect because hirsutism and thin extremities are not typical signs of Cushing's syndrome. Choice C is incorrect as purple striae and muscle weakness are more characteristic of the syndrome. Choice D is also incorrect as hypertension and bruising are not primary signs of Cushing's syndrome.

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