Nursing Elites

1. A client who experienced an acute myocardial infarction expresses concern about fatigue. What is the best strategy to promote self-care?

• A. Ask family members to assist with all self-care tasks
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Instruct the client to remain in bed until fully rested
• D. Assign assistive personnel to complete self-care tasks for the client

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote self-care for a client who experienced an acute myocardial infarction and is experiencing fatigue. This approach helps the client regain independence while managing fatigue. Asking family members to assist with all self-care tasks (Choice A) may hinder the client's independence. Instructing the client to remain in bed until fully rested (Choice C) may lead to deconditioning and dependency. Assigning assistive personnel to complete self-care tasks for the client (Choice D) does not empower the client to regain independence or actively participate in self-care.

2. A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take?

• A. Encourage the client to bear down
• B. Apply the external fetal monitor
• C. Provide the client with fluids
• D. Administer IV fluids

Correct answer: B

Rationale: In this scenario, with the client's cervix dilated to only 1 cm and an unengaged presenting part, the priority action is to apply the external fetal monitor. This allows for continuous monitoring of the fetal heart rate during early labor, which is crucial for assessing fetal well-being. Encouraging the client to bear down is not appropriate at 1 cm dilation, as it may not be effective and can lead to exhaustion. Providing the client with fluids or administering IV fluids may be necessary for hydration, but the immediate concern is monitoring fetal well-being.

3. Which nursing action is a priority when managing a client with a wound infection?

• A. Change the wound dressing every 24 hours
• B. Perform a wound culture before administering antibiotics
• C. Cleanse the wound with alcohol-based solutions
• D. Apply a wet-to-dry dressing to the wound

Correct answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial when managing a client with a wound infection. This step helps identify the specific pathogens causing the infection, allowing for the prescription of the most effective antibiotics. Changing the wound dressing every 24 hours (Choice A) is important for wound care but not the priority when an infection is present. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and may delay wound healing. Applying a wet-to-dry dressing (Choice D) is not recommended for infected wounds as it can cause trauma to the wound bed during dressing changes.

4. A client who is to undergo a colonoscopy is being taught by a nurse about the procedure. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will drink liquids right up until the procedure.
• B. I will need to stop eating and drinking at least 24 hours before the procedure.
• C. I will be sedated and will not feel any pain during the procedure.
• D. I will not need to follow any specific dietary restrictions for this procedure.

Correct answer: C

Rationale: Choice C is the correct answer. During a colonoscopy, clients are typically sedated, so they do not feel any pain during the procedure. Choices A, B, and D are incorrect. Clients are usually required to stop eating and drinking at least 24 hours before a colonoscopy, and there are specific dietary restrictions that need to be followed before the procedure to ensure a successful examination.

5. A client receiving chemotherapy has developed stomatitis. Which of the following actions should the nurse take?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with stomatitis due to chemotherapy is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the already inflamed and sore oral mucosa. Providing lemon-glycerin swabs may further irritate the mucosa due to the acidic nature of lemon. Avoiding toothpaste is advisable as many toothpaste products contain ingredients that can aggravate stomatitis. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol-based mouthwashes can be too harsh and drying for the already sensitive oral tissues.

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