Nursing Elites

1. When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?

• A. Massage the reddened area.
• B. Apply a donut-shaped cushion.
• C. Reposition the client every 3 hours.
• D. Use a transparent film dressing.

Correct answer: D

Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.

2. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?

• A. Tremors
• B. Urine retention
• C. Kussmaul respirations
• D. Bradypnea

Correct answer: C

Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.

3. A healthcare professional is preparing to administer an intradermal injection. Which of the following actions should the professional take?

• A. Use a tuberculin syringe.
• B. Insert the needle at a 45-degree angle.
• C. Use a 1-inch needle.
• D. Aspirate before injecting.

Correct answer: A

Rationale: When administering an intradermal injection, a tuberculin syringe is the appropriate choice due to its small size and precise measurement markings, which are essential for accurately delivering the medication into the dermis layer of the skin. Using a 1-inch needle (choice C) is more common for subcutaneous injections, while inserting the needle at a 45-degree angle (choice B) is typical for intramuscular injections. Aspirating before injecting (choice D) is not necessary for intradermal injections, as the goal is to deliver the medication into the dermis rather than a blood vessel.

4. A healthcare professional is preparing to administer an intramuscular injection to a client. Which of the following actions should the healthcare professional take?

• A. Use a 1-inch needle.
• B. Stretch the skin at the injection site.
• C. Insert the needle at a 90-degree angle.
• D. Aspirate for blood return before injecting.

Correct answer: D

Rationale: Aspirating for blood return before injecting is a crucial step in administering intramuscular injections. This action ensures that the needle is not in a blood vessel, reducing the risk of injecting medication into a blood vessel, which can lead to potential complications. Choices A, B, and C are incorrect. Using a longer 1-inch needle is often necessary for intramuscular injections to reach the muscle tissue properly. Stretching the skin is not recommended as it can cause unnecessary pain and tissue damage. Inserting the needle at a 90-degree angle is the preferred method for intramuscular injections to ensure proper medication delivery.

5. A client has a pressure ulcer. Which of the following findings indicates healing of the ulcer?

• A. Increase in drainage.
• B. Decrease in size.
• C. Presence of foul odor.
• D. Reddened wound edges.

Correct answer: B

Rationale: When a pressure ulcer is healing, there is a decrease in its size as the tissue repair progresses. This reduction in size is a positive indication of the healing process. An increase in drainage, presence of foul odor, or reddened wound edges are typically signs of infection or lack of improvement. Therefore, the correct answer is a decrease in size.

Similar Questions