Nursing Elites

1. A client with limited mobility in their lower extremities is at risk for skin breakdown. Which of the following actions should the nurse take to prevent skin breakdown?

• A. Place the client in high-Fowler's position.
• B. Increase the client's intake of carbohydrates.
• C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion.
• D. Have the client use a trapeze bar when changing position

Correct answer: B

Rationale: The correct answer is B: Increase the client's intake of carbohydrates. Adequate nutrition, including carbohydrates, is essential for tissue repair and preventing skin breakdown. Placing the client in high-Fowler's position (choice A) may help with respiratory function but does not directly prevent skin breakdown. Massaging areas of darker skin (choice C) can cause further damage to the skin. Using a trapeze bar (choice D) may assist with changing positions but does not directly address skin breakdown prevention.

2. Which of the following is an example of a secondary prevention activity?

• A. Blood pressure screening
• B. Administering medications
• C. Developing a care plan
• D. Providing rehabilitation

Correct answer: A

Rationale: The correct answer is A, blood pressure screening. Secondary prevention aims to identify and treat conditions early to prevent their progression. Blood pressure screening helps in early detection of hypertension, allowing for timely intervention. Choices B, C, and D are not examples of secondary prevention activities. Administering medications (B) can be part of treatment after a condition is diagnosed, developing a care plan (C) is more related to organizing and coordinating care rather than prevention, and providing rehabilitation (D) focuses on recovery and improvement post-diagnosis rather than early detection and prevention.

3. The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose

• A. washes the puncture site using warm water and soap
• B. chooses a puncture site in the center of the finger pad
• C. hangs the arm down for a minute before puncturing the site
• D. says the result of 120 mg indicates good blood sugar control

Correct answer: B

Rationale: The correct answer is B because choosing a puncture site in the center of the finger pad is not recommended for blood glucose monitoring. The recommended sites are the sides of the fingertips. Option A is correct as washing the puncture site using warm water and soap is a good practice. Option C is also correct as hanging the arm down for a minute can help increase blood flow. Option D is incorrect as a blood sugar level of 120 mg/dL may not necessarily indicate good blood sugar control and needs further interpretation.

4. A client with frequent tonic-clonic seizures is being admitted. What action should the nurse add to the client's plan of care?

• A. Ensure blankets are placed on all four sides of the bed.
• B. Refrain from using restraints during seizure activity.
• C. Position the client laterally during seizure activity.
• D. Have a tongue depressor available at the client's bedside.

Correct answer: D

Rationale: The correct action the nurse should add to the client's plan of care is to have a tongue depressor available at the client's bedside. This is important during a seizure to prevent the client from biting their tongue. Placing the client laterally helps maintain a clear airway and prevents aspiration, making choice C a good practice during seizure activity. Using restraints during a seizure can cause injuries and should be avoided, making choice B incorrect. Wrapping blankets around all four sides of the bed is unnecessary for seizure management and does not contribute to the client's safety during a seizure, making choice A incorrect.

5. A healthcare professional is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

• A. Airborne
• B. Protective environment
• C. Contact
• D. Droplet

Correct answer: B

Rationale: The correct answer is 'B: Protective environment.' Rubella requires placing the client in a protective environment due to its airborne precautions. Airborne precautions are typically used for diseases that are spread through tiny droplets that remain in the air for an extended period, like tuberculosis. Contact precautions are used for diseases that are spread by direct or indirect contact, such as MRSA. Droplet precautions are implemented for diseases transmitted through respiratory droplets, like influenza. Therefore, in the case of rubella, airborne precautions in a protective environment are necessary.

Similar Questions