Nursing Elites

1. A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water daily.
• B. Wear cotton socks.
• C. Use a heating pad to warm your feet.
• D. Trim toenails straight across.

Correct answer: D

Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.

2. How should signs of dehydration in an elderly patient be assessed?

• A. Monitor skin turgor
• B. Check for dry mucous membranes
• C. Monitor for sunken eyes
• D. Check capillary refill

Correct answer: A

Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.

3. A client with multiple sclerosis and dysphagia requires care. Which intervention should the nurse include in the plan?

• A. Position the client supine with the head of the bed flat.
• B. Have the client tuck their chin while swallowing.
• C. Provide the client with thickened liquids.
• D. Place the food on the unaffected side of the mouth.

Correct answer: C

Rationale: For clients with dysphagia, especially those with multiple sclerosis, thin liquids can increase the risk of aspiration. Thickened liquids are recommended to reduce the risk of aspiration and help with swallowing difficulties. Positioning the client supine with the head of the bed flat can further increase the risk of aspiration. Having the client tuck their chin while swallowing is a strategy used for some types of dysphagia but not specifically for multiple sclerosis-related dysphagia. Placing food on the unaffected side of the mouth does not address the swallowing difficulties associated with dysphagia.

4. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include?

• A. Massage the affected extremity every 4 hours.
• B. Encourage the client to remain on bed rest.
• C. Apply cold packs to the affected extremity.
• D. Encourage the client to ambulate frequently.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply cold packs to the affected extremity. Cold packs help reduce swelling and pain by causing vasoconstriction. Massaging the affected extremity could dislodge a clot, leading to serious complications. Encouraging bed rest may increase the risk of clot propagation, while frequent ambulation is contraindicated as it can dislodge clots.

5. A client who is receiving continuous enteral feedings through a nasogastric tube needs preventive measures to avoid aspiration. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30 degrees.
• B. Check gastric residual volumes every 4 hours.
• C. Administer the feeding at room temperature.
• D. Flush the feeding tube with 20 mL of water every 8 hours.

Correct answer: B

Rationale: The correct answer is to check gastric residual volumes every 4 hours. This action helps prevent aspiration by ensuring the stomach is emptying properly, reducing the risk of reflux and aspiration. Elevating the head of the bed to 30 degrees can help prevent aspiration by promoting proper digestion and reducing the risk of regurgitation. Administering the feeding at room temperature is important for patient comfort but does not directly prevent aspiration. Flushing the feeding tube with water every 8 hours is important for tube patency but does not directly prevent aspiration.

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