Nursing Elites

1. A nurse is caring for a client with a pressure ulcer. Which of the following interventions is most appropriate?

• A. Administer a protein supplement
• B. Increase protein intake in the client's diet
• C. Increase IV fluid intake to improve hydration
• D. Cleanse the wound from the center outwards

Correct answer: D

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps prevent infection and promotes healing by ensuring that any contaminants are moved away from the center of the wound. Administering a protein supplement (choice A) or increasing protein intake in the client's diet (choice B) may be beneficial for overall healing but are not the most appropriate interventions specifically for wound care. Increasing IV fluid intake (choice C) is important for hydration but is not the most appropriate intervention for managing a pressure ulcer.

2. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?

• A. Inject the medication into the muscle of the thigh
• B. Massage the injection site after administration
• C. Pinch the skin before injecting
• D. Administer the medication at the same time each day

Correct answer: C

Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.

3. A client is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?

• A. Encourage the client to bend at the waist
• B. Maintain the client in a high-Fowler's position
• C. Place a pillow between the client's legs
• D. Avoid placing a pillow under the client's knees

Correct answer: C

Rationale: Placing a pillow between the client's legs is beneficial after hip replacement surgery to maintain proper alignment and prevent dislocation of the prosthesis. This position helps keep the hip in a neutral position, reducing the risk of dislocation. Encouraging the client to bend at the waist (Choice A) can increase the risk of hip dislocation. Maintaining the client in a high-Fowler's position (Choice B) and avoiding placing a pillow under the client's knees (Choice D) do not directly address the need to maintain proper alignment of the hip joint to prevent dislocation.

4. A client with peptic ulcer disease is being taught measures to prevent exacerbation of the condition. Which of the following instructions should the nurse include?

• A. Avoid consuming dairy products
• B. Limit alcohol consumption
• C. Use antacids frequently
• D. Drink coffee to improve digestion

Correct answer: B

Rationale: The correct answer is B: Limit alcohol consumption. Alcohol can irritate the stomach lining and worsen peptic ulcer disease. Avoiding dairy products is not necessary unless the client is lactose intolerant. Using antacids frequently may provide symptomatic relief but does not address the root cause of the condition. Drinking coffee can actually stimulate acid production and potentially aggravate peptic ulcers.

5. A healthcare professional is preparing to administer a blood transfusion. What is the first step?

• A. Administer the blood through an IV push
• B. Verify that the client's blood type matches the blood product
• C. Ensure the client has eaten before the transfusion
• D. Administer a diuretic before starting the transfusion

Correct answer: B

Rationale: The correct first step before administering a blood transfusion is to verify that the client's blood type matches the blood product. This step is crucial to prevent transfusion reactions due to incompatibility. Choice A is incorrect because blood should not be administered through an IV push for a blood transfusion. Choice C is incorrect because it is not necessary for the client to eat before a blood transfusion. Choice D is incorrect because administering a diuretic is not a standard practice before starting a blood transfusion.

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