Nursing Elites

1. When providing discharge teaching to a client with diabetes, what is the most important instruction?

• A. Check blood sugar levels once daily
• B. Administer insulin as prescribed before meals
• C. Take medication only when feeling unwell
• D. Eat carbohydrate-rich meals to stabilize blood sugar

Correct answer: B

Rationale: Administering insulin as prescribed before meals is crucial for managing diabetes. This instruction is vital as it helps the client maintain blood sugar levels within the target range. Checking blood sugar levels once daily is important but not as critical as ensuring the timely administration of insulin. Taking medication only when feeling unwell is dangerous as it may lead to uncontrolled blood sugar levels. Eating carbohydrate-rich meals may actually destabilize blood sugar levels rather than stabilizing them, making it an incorrect choice.

2. A client with a pressure ulcer is being cared for by a nurse. Which of the following is the most appropriate action?

• A. Use a phenol solution to clean the wound
• B. Place a warm compress over the wound
• C. Cleanse the wound from the center outwards
• D. Administer antibiotics prophylactically

Correct answer: C

Rationale: Cleaning a wound from the center outwards is the most appropriate action as it helps prevent the spread of infection. Choice A is incorrect as phenol solutions can be harmful to the wound and delay healing. Choice B may increase the risk of infection as warmth can promote bacterial growth. Choice D is unnecessary unless there are signs of infection present.

3. What is an appropriate teaching point for a client with left-leg weakness learning to use a cane?

• A. Maintain two points of support on the ground at all times
• B. Use the cane on the weak side of the body
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: A

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the ground at all times. This ensures stability and helps prevent falls. Choice B, using the cane on the weak side of the body, may lead to imbalance and decreased support. Choice C, advancing the cane a specific distance with each step, is not as crucial as maintaining two points of support. Choice D, advancing the cane and the strong leg simultaneously, may also compromise stability and support for the weak leg.

4. A nurse is reviewing the medical history of a client with dementia. Which of the following findings should the nurse address first?

• A. Restlessness and agitation
• B. Decreased respiratory rate
• C. Wandering during the night
• D. Incontinence

Correct answer: A

Rationale: In a client with dementia, addressing restlessness and agitation is a priority because these symptoms can exacerbate dementia and lead to further complications. Restlessness and agitation can indicate underlying issues such as pain, discomfort, or unmet needs, which should be promptly assessed and managed to improve the client's quality of life. Decreased respiratory rate, wandering during the night, and incontinence are important to address but do not pose immediate risks to the client's well-being compared to the potential effects of unmanaged restlessness and agitation in dementia.

5. A nurse on a med surge unit has received change of shift report and will care for 4 clients. Which of the following clients' needs will the nurse assign to an AP?

• A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
• B. Reinforcing teaching with a client who is learning to walk with a quad cane
• C. Reapplying a condom catheter for a client who has urinary incontinence
• D. Applying a sterile dressing to a pressure ulcer

Correct answer: C

Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely assigned to an assistive personnel (AP) as it falls within their scope of practice. Choice A involves the assessment of a client with aspiration pneumonia, which requires nursing judgment. Choice B requires teaching and guidance, which is the responsibility of the nurse. Choice D involves applying a sterile dressing, which requires nursing skills and knowledge.

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