Nursing Elites

1. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges.
• B. Don sterile gloves.
• C. Normal saline
• D. Determine pain level.

Correct answer: D

Rationale: The correct answer is to determine the pain level first. Assessing the client's pain is crucial before any procedure to ensure their comfort and safety. Applying skin preparation to wound edges (Choice A) may come later in the process after ensuring the client's comfort. Donning sterile gloves (Choice B) is important before directly handling the wound but can follow pain assessment. Normal saline (Choice C) might be used during wound cleansing but is not the initial step in this situation.

2. How should a healthcare professional administer a subcutaneous injection?

• A. Insert the needle at a 45-degree angle
• B. Insert the needle at a 90-degree angle
• C. Use a Z-track method
• D. Insert the needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering subcutaneous injections is to insert the needle at a 45-degree angle. This angle ensures that the medication is delivered into the subcutaneous tissue, which is located just below the skin. Inserting the needle at a 90-degree angle is more appropriate for intramuscular injections, while using a Z-track method is specific to intramuscular injections to prevent leakage of medication into the subcutaneous tissue. Inserting the needle at a 15-degree angle would not reach the subcutaneous tissue effectively.

3. A nurse is reviewing the medical record of a client who has hypothyroidism. Which of the following findings should the nurse expect?

• A. Weight gain of 1.4 kg (3 lb) in the past 2 weeks.
• B. Exophthalmos.
• C. Tachycardia.
• D. Heat intolerance.

Correct answer: A

Rationale: The correct answer is A. Weight gain can indicate myxedema, which is a symptom commonly seen in hypothyroidism. Exophthalmos (choice B) is actually a characteristic finding of hyperthyroidism, not hypothyroidism. Tachycardia (choice C) and heat intolerance (choice D) are also more indicative of hyperthyroidism rather than hypothyroidism.

4. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

• A. Position the client supine.
• B. Prepare an IV bolus of dextrose 5% in water.
• C. Administer methylergonovine IM.
• D. Administer calcium gluconate IV.

Correct answer: D

Rationale: Administering calcium gluconate IV is the correct action when a client displays toxicity from magnesium sulfate. Calcium gluconate is used as the antidote for magnesium sulfate toxicity as it counteracts the effects. Positioning the client supine (Choice A) is not the immediate action needed. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Administering methylergonovine IM (Choice C) is used in postpartum hemorrhage, not for magnesium sulfate toxicity.

5. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?

• A. Use sterile technique when performing tracheostomy care.
• B. Replace the tracheostomy ties every 24 hours.
• C. Use a sterile brush to clean the inner cannula.
• D. Change the tracheostomy dressing once a week.

Correct answer: C

Rationale: The correct answer is to use a sterile brush to clean the inner cannula. This action is crucial to prevent infection during tracheostomy care. Choice A is incorrect as clean technique is not adequate for tracheostomy care, sterile technique is required. Choice B is incorrect as tracheostomy ties should be replaced when soiled, not routinely every 24 hours. Choice D is incorrect as tracheostomy dressings should be changed more frequently to maintain cleanliness and prevent infection.

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