Nursing Elites

1. Which of the following is a key consideration when providing wound care for a client with a pressure ulcer?

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

Correct answer: B

Rationale: Performing a wound culture before applying ointment is crucial when providing wound care for a client with a pressure ulcer. This step helps identify the presence of any infection, allowing for appropriate treatment. Choice A is incorrect because covering the wound with a dry, sterile dressing may not address potential infections. Choice C is incorrect as cleansing the wound with alcohol can be too harsh and drying to the surrounding skin. Choice D is incorrect because covering the wound with a wet-to-dry dressing is not typically recommended for pressure ulcers, as it can cause trauma to the wound bed during removal.

2. A client is learning to use a cane due to left-leg weakness. Which instruction is correct?

• A. Use the cane on the stronger side of the body
• B. Maintain two points of support on the floor at all times
• C. Advance the cane and the strong leg together
• D. Advance the cane 30 to 45 cm with each step

Correct answer: B

Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

3. A client has hyperthermia. Which of the following actions should the nurse take?

• A. Submerge the client's feet in ice water.
• B. Cover the client with a thermal blanket.
• C. Administer oral acetaminophen.
• D. Initiate seizure precautions.

Correct answer: C

Rationale: Administering oral acetaminophen is the appropriate intervention for a client with hyperthermia. Acetaminophen helps to reduce fever by lowering the body's temperature. Submerging the client's feet in ice water can lead to shock and is not recommended. Using a thermal blanket may worsen the condition by trapping heat. Initiating seizure precautions is not directly related to managing hyperthermia.

4. A client with dementia is at risk of falling. What is the best intervention to prevent injury?

• A. Place the client in a room close to the nurses' station
• B. Use a bed exit alarm
• C. Encourage family members to stay with the client at all times
• D. Raise all four side rails

Correct answer: B

Rationale: Using a bed exit alarm is the best intervention to prevent injury in a client with dementia at risk of falling. This device alerts staff when the client attempts to leave the bed, allowing for timely assistance and reducing the risk of falls. Placing the client in a room close to the nurses' station may help with supervision but does not provide immediate alerts like a bed exit alarm. Encouraging family members to stay with the client at all times may not be feasible, and raising all four side rails can lead to restraint issues and is not recommended unless necessary for the client's safety.

5. What should a person recommend to a client experiencing constipation?

• A. Increase fluid intake to prevent further dehydration
• B. Increase dietary fiber to promote regular bowel movements
• C. Administer a laxative to relieve constipation
• D. Encourage bed rest to allow for bowel function to return

Correct answer: B

Rationale: Increasing dietary fiber is an effective recommendation for clients experiencing constipation as it helps promote regular bowel movements. Choice A, increasing fluid intake, is also important but the most appropriate initial recommendation for constipation is to increase dietary fiber. Choice C, administering a laxative, should not be the first-line recommendation and is typically considered after dietary and lifestyle interventions. Choice D, encouraging bed rest, does not directly address constipation relief or prevention.

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