Nursing Elites

1. What action should the nurse include in the plan of care for a postoperative client with a history of poor nutritional intake who needs care for wound healing?

• A. Provide a protein intake of 1.5 g/kg of body weight per day.
• B. Increase carbohydrate intake to 50% of daily calories.
• C. Administer high-dose vitamin supplements.
• D. Ensure a daily intake of 1000 calories.

Correct answer: A

Rationale: To promote wound healing in a postoperative client with poor nutritional intake, the nurse should include a protein intake of 1.5 g/kg of body weight per day in the plan of care. Proteins are essential for tissue repair and wound healing. Increasing carbohydrate intake or administering high-dose vitamin supplements may not directly promote wound healing. Ensuring a daily intake of 1000 calories may not provide adequate nutrients for optimal wound healing.

2. When moving a patient up in bed using a drawsheet with the help of another nurse, in which order will the nurses perform the steps, starting with the first one?

• A. Grasp the drawsheet firmly near the patient.
• B. Move the patient and drawsheet to the desired position.
• C. Position one nurse at each side of the bed.
• D. Place the drawsheet under the patient from shoulder to thigh.

Correct answer: C

Rationale: When moving a patient up in bed with a drawsheet and the assistance of another nurse, it is important to have one nurse positioned at each side of the bed initially. This allows for proper coordination and support during the patient movement. Placing the drawsheet under the patient from shoulder to thigh, grasping the drawsheet firmly near the patient, and moving the patient and drawsheet to the desired position follow after the nurses are positioned on each side of the bed. The correct sequence ensures a safe and coordinated approach to repositioning the patient in bed.

3. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?

• A. Our child had chickenpox 6 months ago.
• B. Strep throat went through all the children at the day care last month.
• C. Both ears were infected over 3 months ago.
• D. Last week both feet had a fungal skin infection.

Correct answer: B

Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.

4. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

• A. Pad the client’s wrists before applying the restraints
• B. Tie the restraints to the side rails of the bed
• C. Secure the restraints to the bed frame
• D. Use a quick-release knot to tie the restraints

Correct answer: A

Rationale: The correct action for the nurse to take when a client has a new prescription for wrist restraints is to pad the client’s wrists before applying the restraints. This is important to prevent skin breakdown and injury. Tying the restraints to the side rails of the bed (Choice B) is unsafe and can lead to potential harm for the client. Similarly, securing the restraints to the bed frame (Choice C) is not appropriate as it can restrict the client's movement and cause discomfort. Using a quick-release knot to tie the restraints (Choice D) is also incorrect as it may compromise the effectiveness of the restraints in ensuring client safety.

5. A healthcare professional is assessing an adult client who has been immobile for the past 3 weeks. The healthcare professional should identify that which of the following findings requires further intervention?

• A. Erythema on pressure points
• B. Lower-extremity pulse strength of 2+
• C. Fluid intake of 3,000 mL per day
• D. A bowel movement every other day

Correct answer: A

Rationale: Erythema on pressure points indicates potential skin breakdown due to prolonged immobility. It requires immediate intervention to prevent pressure ulcers. Lower-extremity pulse strength of 2+ is a normal finding, indicating adequate peripheral perfusion. Fluid intake of 3,000 mL per day is within the normal range and promotes hydration. A bowel movement every other day is a reasonable frequency for some individuals and does not necessarily indicate a need for immediate intervention in this scenario.

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