Nursing Elites

1. A nurse is providing discharge instructions to a client with oxygen therapy. What should the nurse emphasize?

• A. Avoid keeping oxygen tanks in an upright position
• B. Keep oxygen equipment at least 6 feet away from heat sources
• C. Allow family members to smoke in designated areas
• D. Restrict fluid intake while using oxygen therapy

Correct answer: B

Rationale: The correct answer is B: 'Keep oxygen equipment at least 6 feet away from heat sources.' It is crucial to keep oxygen equipment away from heat sources to prevent fire hazards. Option A is incorrect as oxygen tanks should be stored in an upright position. Option C is wrong because smoking near oxygen equipment poses a significant fire risk. Option D is also incorrect as fluid intake should not be restricted while using oxygen therapy; in fact, it is important to maintain adequate hydration.

2. A client undergoing radiation therapy is being taught about skin care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will use a heating pad to soothe the skin
• B. I will avoid using perfumed lotions on the treated area
• C. I will apply cold compresses to the area
• D. I will scrub the area daily with soap and water

Correct answer: B

Rationale: The correct answer is B because avoiding perfumed lotions is important to prevent skin irritation after radiation therapy. Using a heating pad (A) can further damage the skin, applying cold compresses (C) may not be recommended, and scrubbing the area daily with soap and water (D) can be too harsh on the skin, leading to further irritation and damage.

3. When assessing a client with signs of delirium, which factor should be the nurse's priority in determining the cause?

• A. Medication history
• B. Fluid and electrolyte imbalances
• C. Psychosocial stressors
• D. Environmental factors

Correct answer: B

Rationale: When a nurse assesses a client with signs of delirium, the priority in determining the cause should be focusing on fluid and electrolyte imbalances. Delirium can often be linked to imbalances in these essential elements, making it crucial to address them promptly. While medication history, psychosocial stressors, and environmental factors can also contribute to delirium, they should be assessed after addressing fluid and electrolyte imbalances due to their immediate impact on cognitive function.

4. What is the priority nursing intervention for a patient with chest pain?

• A. Administer nitroglycerin
• B. Assess pain level
• C. Monitor vital signs
• D. Provide oxygen therapy

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with chest pain because it helps relieve chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Assessing pain level, monitoring vital signs, and providing oxygen therapy are important interventions as well, but administering nitroglycerin takes precedence in addressing the immediate symptom of chest pain and potential cardiac ischemia.

5. What are the steps in managing a patient with a pressure ulcer?

• A. Clean the wound and apply a hydrocolloid dressing
• B. Debride necrotic tissue and apply antibiotics
• C. Apply an alginate dressing and elevate the affected area
• D. Use moisture-retentive dressings and reposition frequently

Correct answer: A

Rationale: The correct answer is A: Clean the wound and apply a hydrocolloid dressing. This step is crucial in managing a pressure ulcer as it helps protect the ulcer from infection and promotes healing by creating a moist environment conducive to tissue repair. Choice B, debriding necrotic tissue and applying antibiotics, is more suitable for managing infected pressure ulcers but not as the initial step. Choice C, applying an alginate dressing and elevating the affected area, may be part of the management but is not the initial step. Choice D, using moisture-retentive dressings and repositioning frequently, is important for prevention but not the first step in managing an existing pressure ulcer.

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