Nursing Elites

1. When caring for a client with a wound infection, what should the nurse prioritize?

• A. Change the dressing daily
• B. Cleanse the wound with an antiseptic solution
• C. Apply a wet-to-dry dressing to the wound
• D. Perform a wound culture before administering antibiotics

Correct answer: D

Rationale: The nurse should prioritize performing a wound culture before administering antibiotics to ensure appropriate treatment. This step helps identify the specific infecting organism and its susceptibility to different antibiotics, guiding effective antibiotic therapy. Changing the dressing daily (Choice A) is important but comes after assessing the infection and initiating appropriate treatment. Cleansing the wound with an antiseptic solution (Choice B) and applying a wet-to-dry dressing (Choice C) are interventions that may be necessary but are secondary to determining the most suitable antibiotic therapy based on the wound culture results.

2. What is a primary symptom of left-sided heart failure?

• A. Shortness of breath
• B. Edema
• C. Rapid heartbeat
• D. Confusion

Correct answer: A

Rationale: Shortness of breath is a primary symptom of left-sided heart failure. In this condition, the heart's inability to pump effectively leads to fluid backing up into the lungs, causing difficulty breathing. Edema (swelling), rapid heartbeat, and confusion are more commonly associated with other conditions or right-sided heart failure. Edema is often seen in right-sided heart failure due to fluid accumulation in the body, rapid heartbeat can be a general sign of heart issues, and confusion is more related to decreased brain perfusion in severe heart failure cases.

3. A nurse is caring for a client with an NG tube who is experiencing nausea and decreased gastric secretions. What is the priority nursing action?

• A. Increase the suction pressure
• B. Turn the client onto their side
• C. Irrigate the NG tube with sterile water
• D. Replace the NG tube with a new one

Correct answer: D

Rationale: The correct answer is to replace the NG tube with a new one. When a client with an NG tube experiences nausea and decreased gastric secretions, it indicates a possible problem with the tube itself. Replacing the tube ensures proper functioning and can alleviate the symptoms. Increasing the suction pressure (Choice A) can worsen the client's condition. Turning the client onto their side (Choice B) may be helpful in some situations but does not address the underlying issue. Irrigating the NG tube with sterile water (Choice C) is not the priority and may not resolve the problem.

4. A nurse is reviewing the medical history of a client with dementia. Which of the following findings should the nurse address first?

• A. Restlessness and agitation
• B. Decreased respiratory rate
• C. Wandering during the night
• D. Incontinence

Correct answer: A

Rationale: In a client with dementia, addressing restlessness and agitation is a priority because these symptoms can exacerbate dementia and lead to further complications. Restlessness and agitation can indicate underlying issues such as pain, discomfort, or unmet needs, which should be promptly assessed and managed to improve the client's quality of life. Decreased respiratory rate, wandering during the night, and incontinence are important to address but do not pose immediate risks to the client's well-being compared to the potential effects of unmanaged restlessness and agitation in dementia.

5. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant?

• A. Allow the client to rest four to five times during the day
• B. Assess the cognitive functioning of the client regularly
• C. Provide reality orientation even if the memory loss is severe
• D. Maintain consistency in environment, routine, and caregivers

Correct answer: D

Rationale: The most relevant suggestion for minimizing stress in individuals with Alzheimer's disease is to maintain consistency in the environment, routine, and caregivers. This approach helps create a sense of familiarity and security for the individual, reducing stress and anxiety. Choice A is incorrect as it suggests allowing the client to go to bed multiple times during the day, which may disrupt their routine and lead to confusion. Choice B is incorrect as continuously testing cognitive functioning can be overwhelming and stressful for the individual. Choice C is also incorrect as providing reality orientation in cases of severe memory loss can cause frustration and confusion, ultimately increasing stress levels.

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