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. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

3. A client is being assessed for dehydration. Which of the following findings should the nurse expect?

• A. Elevated blood pressure
• B. Increased skin turgor
• C. Dark-colored urine
• D. Bradypnea

Correct answer: C

Rationale: Dark-colored urine is a common sign of dehydration as the urine becomes concentrated. Dehydration leads to reduced fluid intake or excessive fluid loss, causing the urine to be darker in color due to increased urine concentration. Elevated blood pressure (Choice A) is not typically associated with dehydration; instead, dehydration often leads to low blood pressure. Increased skin turgor (Choice B) is actually a sign of good hydration, not dehydration. Bradypnea (Choice D), which refers to abnormally slow breathing, is not a common finding in dehydration.

4. A healthcare professional is preparing to administer an intradermal injection. Which of the following actions should the professional take?

• A. Use a tuberculin syringe.
• B. Insert the needle at a 45-degree angle.
• C. Use a 1-inch needle.
• D. Aspirate before injecting.

Correct answer: A

Rationale: When administering an intradermal injection, a tuberculin syringe is the appropriate choice due to its small size and precise measurement markings, which are essential for accurately delivering the medication into the dermis layer of the skin. Using a 1-inch needle (choice C) is more common for subcutaneous injections, while inserting the needle at a 45-degree angle (choice B) is typical for intramuscular injections. Aspirating before injecting (choice D) is not necessary for intradermal injections, as the goal is to deliver the medication into the dermis rather than a blood vessel.

5. When providing teaching to a client with a new prescription for digoxin, which of the following instructions should the nurse include?

• A. Take your pulse before taking the medication.
• B. Take the medication with an antacid.
• C. Double the dose if you miss one.
• D. Take the medication with a high-fiber meal.

Correct answer: A

Rationale: The correct instruction for a client with a new prescription for digoxin is to take their pulse before taking the medication. Digoxin can lead to bradycardia as a side effect, and monitoring the pulse helps in assessing the heart rate prior to medication administration. This precaution allows for the identification of any significant changes in heart rate that may require medical attention.

Similar Questions