Nursing Elites

1. When teaching a client with a new diagnosis of diabetes mellitus about foot care, which of the following instructions should the nurse include?

• A. Soak your feet in hot water every day.
• B. Apply lotion between your toes.
• C. Inspect your feet daily.
• D. Use over-the-counter products to remove corns.

Correct answer: C

Rationale: Inspecting the feet daily is crucial for clients with diabetes mellitus to detect early signs of injury or infection promptly. This practice helps prevent serious complications such as diabetic foot ulcers. Soaking feet in hot water daily can lead to skin dryness and increase the risk of injury. Applying lotion between toes can cause moisture buildup, leading to fungal infections. Using over-the-counter products to remove corns can result in skin damage and should be done under healthcare provider supervision.

2. Which of the following dietary modifications should be recommended to a client with hypertension?

• A. Increase sodium intake.
• B. Reduce potassium intake.
• C. Increase fiber intake.
• D. Reduce calcium intake.

Correct answer: C

Rationale: Increasing fiber intake is a beneficial dietary modification for clients with hypertension. Fiber helps in reducing blood pressure and improving cardiovascular health by promoting better digestion and regulating cholesterol levels. Therefore, advising a client with hypertension to increase fiber intake can be beneficial for their overall health. In contrast, increasing sodium intake can lead to higher blood pressure, reducing potassium intake is not recommended as potassium helps in regulating blood pressure, and reducing calcium intake is not typically necessary for hypertension management.

3. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30°
• B. Flush the tube with 50 mL of water every 2 hours
• C. Replace the feeding bag and tubing every 72 hours
• D. Check the client's gastric residual every 8 hours

Correct answer: A

Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.

4. Following a total hip arthroplasty, what intervention should the healthcare provider implement for the client?

• A. Place a pillow between the client's legs.
• B. Elevate the head of the bed to 45 degrees.
• C. Position the client on the operative side.
• D. Keep the client’s legs adducted.

Correct answer: A

Rationale: Placing a pillow between the client's legs is crucial post hip arthroplasty surgery to prevent hip dislocation. This intervention helps maintain proper alignment and prevents legs from crossing midline, reducing the risk of hip prosthesis dislocation. Elevating the head of the bed to 45 degrees, positioning the client on the operative side, or keeping the client's legs adducted are not recommended postoperative interventions for a total hip arthroplasty, as they can increase the risk of complications and compromise the surgical site.

5. A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?

• A. Insert the rectal tube 15.2 cm (6 inches) into the client's rectum
• B. Wear clean gloves before inserting the tubing
• C. Position the client on their left side
• D. Hold the solution bag 91 cm (36 inches) above the client's rectum

Correct answer: C

Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.

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