Nursing Elites

1. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

• A. Frequent repositioning
• B. Poor nutrition
• C. Increased fluid intake
• D. Use of a special mattress

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

2. A client is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates understanding?

• A. I can change my living will whenever I want.
• B. I do not need a living will if I have a durable power of attorney.
• C. My family will make decisions for me if I am unable to.
• D. I need a living will only if I am seriously ill.

Correct answer: A

Rationale: The correct answer is A because the client understanding that they can change their living will whenever they want shows comprehension of advance directives. Choices B, C, and D are incorrect: B is inaccurate as both documents serve different purposes; C may not always be the case based on the client's wishes and legal documents; D is incorrect because a living will is not only for serious illness but also for end-of-life care decisions.

3. A nurse is assessing a client who has received intermittent enteral feedings. What finding indicates the client is tolerating the feeding?

• A. Nausea and vomiting
• B. Normal bowel sounds
• C. Weight gain
• D. Decreased abdominal distention

Correct answer: D

Rationale: The correct answer is D: Decreased abdominal distention. This finding indicates that the client is tolerating the feeding well without experiencing bloating or discomfort. Nausea and vomiting (choice A) are symptoms of intolerance to enteral feedings. Normal bowel sounds (choice B) are a good sign but do not directly indicate tolerance to the feeding. Weight gain (choice C) may occur due to factors other than enteral feedings.

4. While assessing the IV infusion site of a client experiencing pain, redness, and warmth, 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. Pain, redness, and warmth at the IV site are signs of phlebitis, which is inflammation of the vein. Continuing the infusion can further irritate the vein and lead to complications. Increasing the IV flow rate would exacerbate the issue by delivering more irritants to the vein. Elevating the limb and applying a cold compress are not the appropriate interventions for phlebitis, as discontinuing the infusion is crucial to prevent further harm.

5. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?

• A. Apply a heating pad to the wound
• B. Apply a moisture-retentive dressing
• C. Provide daily wound irrigation
• D. Apply an ice pack to the wound

Correct answer: B

Rationale: The correct answer is to apply a moisture-retentive dressing. This type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.

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