Nursing Elites

1. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?

• A. Apply a heating pad to the wound
• B. Apply a moisture-retentive dressing
• C. Provide daily wound irrigation
• D. Apply an ice pack to the wound

Correct answer: B

Rationale: The correct answer is to apply a moisture-retentive dressing. This type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.

2. A client is being taught how to use a cane. Which instruction should the nurse include?

• A. Use the cane on the stronger side
• B. Use the cane on the weaker side
• C. Ensure the cane has a rubber tip
• D. Hold the cane 1-2 inches from the ground

Correct answer: A

Rationale: The correct answer is to use the cane on the stronger side. This instruction is important because it provides better support and balance. Placing the cane on the stronger side helps to shift weight off the weaker or injured side, reducing the risk of falls and promoting stability. Choices B, C, and D are incorrect. Using the cane on the weaker side would not provide optimal support. While ensuring the cane has a rubber tip and holding it 1-2 inches from the ground are important, they are not as crucial as using the cane on the stronger side for proper support and balance.

3. A nurse is teaching a group of assistive personnel about expected integumentary changes in older adults. What change should the nurse include?

• A. Increase in oil production
• B. Decrease in elasticity
• C. Increase in pigmentation
• D. Decrease in moisture levels

Correct answer: B

Rationale: The correct answer is B: Decrease in elasticity. As individuals age, their skin tends to lose elasticity, becoming less flexible. This results in wrinkles and sagging skin. Option A, increase in oil production, is not typically an expected integumentary change in older adults. Option C, increase in pigmentation, may occur due to sun exposure or age spots but is not a universal change. Option D, decrease in moisture levels, is not a primary integumentary change associated with aging.

4. A nurse is assessing a client who reports pain at the site of a peripheral IV. The site is red and warm. What is the nurse's priority action?

• A. Flush the IV line with saline
• B. Discontinue the IV infusion
• C. Apply a cold compress
• D. Increase the IV flow rate

Correct answer: B

Rationale: The correct answer is to discontinue the IV infusion. The signs of redness and warmth at the IV site indicate phlebitis, an inflammation of the vein. Discontinuing the IV infusion is crucial to prevent further complications such as infection or thrombosis. Flushing the IV line with saline would not address the underlying issue of phlebitis. Applying a cold compress may provide temporary relief but does not address the cause. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

5. A nurse is preparing to administer enteral feedings to a client with a nasogastric (NG) tube. What action should the nurse take first?

• A. Measure the residual gastric volume
• B. Verify tube placement
• C. Flush the tube with 100 mL of water
• D. Administer the feeding in small boluses

Correct answer: B

Rationale: Verifying tube placement is the crucial initial step a nurse should take before administering enteral feedings through an NG tube. This step ensures that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Measuring residual gastric volume, flushing the tube with water, or administering the feeding in small boluses are all important steps in enteral feeding but should only be done after confirming the correct tube placement.

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