Nursing Elites

1. A client with a new diagnosis of diabetes mellitus needs instruction on foot care. What advice should the nurse provide?

• A. Soak feet in warm water daily
• B. Wear shoes at all times
• C. Cut toenails in a rounded shape
• D. Inspect the feet weekly

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes at all times.' This instruction is crucial for clients with diabetes as it helps protect the feet from potential injuries. Choice A of soaking feet in warm water daily can lead to skin issues and should be avoided. Cutting toenails in a rounded shape, as mentioned in choice C, can increase the risk of ingrown toenails. While inspecting the feet weekly, as in choice D, is important, wearing shoes at all times is a more preventative measure to avoid foot injuries in diabetic clients.

2. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Administer antihypertensive medication
• B. Notify the healthcare provider
• C. Recheck the blood pressure
• D. Document the blood pressure in the chart

Correct answer: C

Rationale: The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.

3. A nurse is reviewing a client's health history and identifies chronic constipation as a potential complication of immobility. What intervention should the nurse include in the plan of care?

• A. Increase fiber intake
• B. Encourage the client to walk daily
• C. Use a stool softener as needed
• D. Use a laxative daily

Correct answer: A

Rationale: Increasing fiber intake is the appropriate intervention to include in the plan of care for a client with chronic constipation due to immobility. Fiber helps add bulk to the stool, making it easier to pass, thereby preventing constipation. Encouraging the client to walk daily (choice B) is also beneficial as it promotes mobility and can help alleviate constipation associated with immobility. Using a stool softener as needed (choice C) and using a laxative daily (choice D) are not the first-line interventions for managing constipation related to immobility. Stool softeners and laxatives should be used judiciously and under healthcare provider guidance.

4. A nurse is caring for a client who has experienced a seizure. What should the nurse do immediately after the seizure?

• A. Administer oxygen
• B. Document the seizure activity
• C. Turn the client on their side
• D. Reassure the client

Correct answer: C

Rationale: After a client experiences a seizure, the nurse should immediately turn the client on their side. This action helps maintain an open airway and prevents aspiration, as it allows any secretions or vomitus to drain from the mouth. Administering oxygen can be necessary if the client is hypoxic, but turning the client on their side takes precedence to prevent complications. While documenting the seizure activity is important for the client's medical record, ensuring the client's immediate safety by positioning them correctly is the priority. Reassuring the client should follow after ensuring their physical safety.

5. A nurse is caring for a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?

• A. Irrigate the catheter with normal saline
• B. Notify the provider
• C. Apply a warm compress to the site
• D. Administer pain medication

Correct answer: B

Rationale: The correct first action for the nurse to take when a client reports pain at the site of an indwelling urinary catheter is to notify the provider. Pain at the catheter site may indicate complications such as infection or blockage, which require further assessment and intervention by the healthcare provider. Irrigating the catheter, applying a warm compress, or administering pain medication should not be done without provider evaluation as they do not address the underlying cause of the pain and may potentially worsen the situation.

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