Nursing Elites

1. A nurse is reviewing a client's health history and identifies urinary incontinence as a risk factor for pressure injuries. What should the nurse include in the plan of care?

• A. Use a heating pad for comfort
• B. Apply a barrier cream to the skin
• C. Reposition the client every 4 hours
• D. Change the client's position every 2 hours

Correct answer: C

Rationale: The correct answer is to reposition the client every 4 hours. Repositioning the client helps prevent pressure injuries caused by urinary incontinence by relieving pressure on vulnerable areas of the skin. Choice A, using a heating pad for comfort, is not directly related to preventing pressure injuries. Choice B, applying a barrier cream to the skin, may help protect the skin but does not address the underlying cause of pressure injuries. Choice D, changing the client's position every 2 hours, is more frequent than necessary and may not be as effective in preventing pressure injuries as repositioning every 4 hours.

2. While documenting client care, which entry should the nurse identify as an example of implementing client care?

• A. Documenting the client's pain level
• B. Monitoring the client's urine output
• C. Assessing the client's range of motion
• D. Contacting the provider to report client findings

Correct answer: D

Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.

3. A client has a new prescription for a metered-dose inhaler (MDI). What instruction should the nurse include?

• A. Inhale the medication for 1 second
• B. Shake the inhaler vigorously before use
• C. Hold the inhaler 1-2 inches from the mouth
• D. Exhale immediately after inhalation

Correct answer: C

Rationale: The correct instruction for a client using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance allows for the proper delivery of the medication into the lungs. Choice A is incorrect because the duration of inhalation can vary depending on the medication, and 1 second may not be adequate. Choice B is incorrect as shaking the inhaler vigorously is not necessary for all MDIs and can lead to inaccurate dosing. Choice D is incorrect as the client should hold their breath for about 10 seconds after inhalation to allow the medication to deposit in the lungs.

4. A client who is at risk for developing a deep vein thrombosis (DVT) after surgery. What intervention should the nurse implement to reduce this risk?

• A. Avoid ambulation to prevent injury
• B. Use compression stockings
• C. Use a heating pad for comfort
• D. Elevate the client's legs on a pillow

Correct answer: B

Rationale: The correct intervention to reduce the risk of deep vein thrombosis (DVT) after surgery is to use compression stockings. Compression stockings help prevent DVT by promoting venous return, which reduces the likelihood of blood pooling in the legs and forming clots. Choices A, C, and D are incorrect because avoiding ambulation can actually increase the risk of DVT, using a heating pad does not directly address DVT prevention, and elevating the client's legs on a pillow alone may not provide sufficient compression to prevent DVT.

5. A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. Which term should the nurse use to document this finding?

• A. Papule
• B. Macule
• C. Nodule
• D. Tumor

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion is less than 0.5cm, fitting the description of a macule. A papule (choice A) is a solid, elevated lesion less than 0.5 cm in diameter. A nodule (choice C) is a solid, elevated lesion that is 0.5 cm or larger in diameter. A tumor (choice D) refers to a mass of abnormal tissue growth, which is not applicable in this scenario.

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