Nursing Elites

1. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?

• A. Apply a dry dressing.
• B. Cleanse the wound with normal saline.
• C. Perform debridement as needed.
• D. Apply a hydrocolloid dressing.

Correct answer: D

Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.

2. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should the nurse identify as an indication of a hemolytic transfusion reaction?

• A. Low back pain.
• B. Bradycardia.
• C. Chills.
• D. Distended neck veins.

Correct answer: A

Rationale: The correct answer is A: Low back pain. Low back pain is a common sign of a hemolytic transfusion reaction, indicating the destruction of red blood cells. This finding requires immediate intervention as it can lead to serious complications such as renal failure. Bradycardia (choice B) is not typically associated with a hemolytic transfusion reaction. Chills (choice C) can be seen in febrile non-hemolytic transfusion reactions. Distended neck veins (choice D) are more indicative of fluid overload rather than a hemolytic reaction.

3. A nurse is caring for a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

• A. Apply the patch to the same location each time.
• B. Rotate the patch site daily to avoid skin irritation.
• C. Apply the patch in the morning and remove it at bedtime.
• D. Keep the patch on at all times, even during a bath.

Correct answer: C

Rationale: The correct answer is to apply the nitroglycerin transdermal patch in the morning and remove it at bedtime. This schedule helps prevent tolerance to the medication. Choice A is incorrect because the patch should be rotated to different sites to prevent skin irritation. Choice B is incorrect as daily rotation is recommended, not daily application to the same site. Choice D is incorrect as the patch should be removed during a bath as it may decrease the efficacy of the medication.

4. A nurse is caring for a client who has diabetes insipidus. Which of the following findings should the nurse expect?

• A. Weight gain
• B. Increased urine output
• C. Bradycardia
• D. Hyperactive bowel sounds

Correct answer: B

Rationale: Increased urine output is a key finding in clients with diabetes insipidus due to a deficiency of antidiuretic hormone. Weight gain (choice A) is not expected in diabetes insipidus as it is a condition characterized by excessive thirst and urination leading to fluid loss. Bradycardia (choice C) and hyperactive bowel sounds (choice D) are not typically associated with diabetes insipidus.

5. A client is receiving radiation therapy for cancer. Which of the following skin care instructions should the nurse include in the teaching?

• A. Apply alcohol-free lotions to your skin to prevent dryness.
• B. Avoid exposing the irradiated area to direct sunlight.
• C. Cleanse the irradiated area with mild soap and water.
• D. Apply ice packs to the irradiated area to prevent swelling.

Correct answer: B

Rationale: The correct answer is to avoid exposing the irradiated area to direct sunlight. Direct sunlight can further damage the skin during radiation therapy. Choice A is incorrect because alcohol-based lotions can irritate the skin further. Choice C is incorrect because mild soap and water can be drying to the skin. Choice D is incorrect because applying ice packs can cause additional skin damage during radiation therapy.

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