Nursing Elites

1. A client with diabetes mellitus is receiving discharge instructions about foot care from a nurse. Which statement indicates an understanding of the teaching?

• A. I will soak my feet in hot water daily
• B. I will wear shoes at all times
• C. I will cut my toenails in a rounded shape
• D. I will apply lotion between my toes after bathing

Correct answer: B

Rationale: The correct answer is B: 'I will wear shoes at all times.' This statement demonstrates an understanding of foot care for a client with diabetes. Wearing shoes at all times helps protect the feet, reducing the risk of injury and complications such as wounds or infections. Option A is incorrect because soaking feet in hot water can lead to skin dryness and increase the risk of burns or injury for individuals with diabetes. Option C is incorrect as cutting toenails in a rounded shape can cause ingrown toenails and potential infections. Option D is also incorrect as applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.

2. A client at risk for pressure injuries is being cared for by a nurse. What intervention should the nurse implement?

• A. Keep the client in one position
• B. Use a special mattress for the client
• C. Turn the client every 4 hours
• D. Provide extra pillows for positioning

Correct answer: B

Rationale: The correct intervention for a client at risk for pressure injuries is to use a special mattress. Special mattresses help reduce the risk of pressure injuries by redistributing pressure on bony areas, thus preventing tissue damage. Keeping the client in one position (choice A) can actually increase the risk of pressure injuries due to prolonged pressure on specific areas. Turning the client every 4 hours (choice C) is important for preventing pressure injuries, but using a special mattress is a more effective intervention. Providing extra pillows for positioning (choice D) may offer some comfort but does not address the primary intervention of pressure redistribution that a special mattress provides.

3. A nurse is caring for a client who has dementia and frequently tries to get out of bed. What actions should the nurse take? (Select all that apply)

• A. Turn off the bed alarm
• B. Use physical restraints
• C. Maintain the bed in the lowest position
• D. Apply a vest restraint

Correct answer: C

Rationale: Maintaining the bed in the lowest position is an appropriate action when caring for a client with dementia who tries to get out of bed. This helps reduce the risk of falls and ensures the client's safety. Turning off the bed alarm (Choice A) is not advisable as it can be a safety measure to alert the staff when the client tries to get out of bed. Using physical restraints (Choice B) and applying a vest restraint (Choice D) should be avoided as they can lead to physical and psychological harm, reduce mobility, and compromise the client's dignity.

4. A nurse is planning to administer multiple medications to a client with dysphagia. What action should the nurse take?

• A. Crush medications and mix them with honey
• B. Provide medications through a straw
• C. Place the medications in small amounts of pudding
• D. Offer the medications with a full glass of water

Correct answer: C

Rationale: The correct action for the nurse to take when administering medications to a client with dysphagia is to place the medications in small amounts of pudding. Mixing medications with pudding helps clients with dysphagia swallow them more easily. Choice A (crushing medications and mixing with honey) is not recommended as it may alter the medication properties. Choice B (providing medications through a straw) is not suitable for clients with dysphagia as it can pose a choking hazard. Choice D (offering medications with a full glass of water) may be difficult for clients with dysphagia to swallow and increase the risk of aspiration.

5. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.

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