Nursing Elites

1. A nurse is caring for a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?

• A. I can't brush my teeth properly
• B. I am so frustrated I can't open my milk carton
• C. I can't hold a pencil
• D. I can't write anymore

Correct answer: B

Rationale: The correct answer is B. The client's frustration with opening a milk carton indicates difficulty with activities of daily living, which is a common concern addressed by occupational therapists. Choices A, C, and D are related to fine motor skills, which may also be addressed by an occupational therapist but are not as directly linked to activities of daily living as struggling with tasks like opening containers.

2. What are the nursing interventions for a patient with a pressure ulcer?

• A. Clean the wound and apply a hydrocolloid dressing
• B. Provide a high-protein diet and ensure bed rest
• C. Monitor for signs of infection and provide antibiotics
• D. Provide a low-sodium diet and monitor for fluid retention

Correct answer: A

Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.

3. What is an early sign indicating the need for suctioning a client's tracheostomy?

• A. Irritability
• B. Hypotension
• C. Flushing
• D. Bradycardia

Correct answer: A

Rationale: Irritability is a crucial early sign that a client with a tracheostomy may require suctioning. Irritability could indicate a lack of oxygenation due to the airway blockage, prompting the need for suctioning to clear the airway. Hypotension, flushing, and bradycardia are not typically direct indicators for suctioning a tracheostomy. Hypotension may suggest hemodynamic instability, flushing could be related to autonomic responses, and bradycardia might indicate a cardiac issue rather than the need for suctioning.

4. What are the key interventions in managing a patient with diabetic ketoacidosis (DKA)?

• A. Administer insulin and fluids
• B. Administer oral hypoglycemics
• C. Administer glucagon
• D. Administer insulin and monitor blood glucose

Correct answer: A

Rationale: The correct intervention in managing a patient with diabetic ketoacidosis (DKA) is to administer insulin and fluids. Insulin is crucial to correct hyperglycemia, while fluids are important to address dehydration. Administering oral hypoglycemics (Choice B) is not appropriate in the management of DKA as the patient may not be able to absorb oral medications due to gastrointestinal issues. Glucagon (Choice C) is not indicated in the treatment of DKA. Although monitoring blood glucose (Choice D) is important, it is not the sole key intervention for managing DKA; administering insulin and fluids are the primary interventions.

5. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?

• A. Cancer of any kind
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

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