Nursing Elites

1. A client with diabetes mellitus is being taught about the importance of foot care by a nurse. Which instruction should the nurse include?

• A. Cut toenails straight across
• B. Wear shoes at all times
• C. Soak feet in hot water daily
• D. Apply lotion between the toes

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes at all times.' Clients with diabetes are at a higher risk of foot complications due to poor circulation and nerve damage. Wearing shoes at all times helps protect their feet from injuries. Choice A is incorrect because toenails should be cut straight across to prevent ingrown toenails. Choice C is incorrect as soaking feet in hot water can lead to burns or skin damage, especially for those with diabetes who may have reduced sensation. Choice D is incorrect because applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.

2. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Apply a moisture-retentive dressing
• C. Apply a heating pad to the site
• D. Keep the client on bedrest

Correct answer: B

Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.

3. A client with diabetes mellitus is being taught about foot care. What statement by the client indicates an understanding of the teaching?

• A. I will soak my feet in warm water every day
• B. I will wear slippers at all times when out of bed
• C. I will apply lotion between my toes after washing my feet
• D. I will cut my toenails straight across

Correct answer: B

Rationale: The correct answer is B. Wearing slippers or shoes at all times when out of bed is crucial for clients with diabetes mellitus to protect their feet from injury. Option A is incorrect as soaking feet in warm water can lead to dry skin, making it more susceptible to injuries. Option C is incorrect as applying lotion between the toes can create a moist environment, increasing the risk of fungal infections. Option D is incorrect as cutting toenails straight across is a good practice but is not directly related to preventing foot injuries in clients with diabetes.

4. A client is found on the floor experiencing a seizure. What is the nurse's priority action?

• A. Apply oxygen
• B. Place the client on their side
• C. Administer an anticonvulsant
• D. Notify the provider

Correct answer: B

Rationale: The nurse's priority action when finding a client experiencing a seizure is to place the client on their side. This action helps maintain an open airway and prevents aspiration, which is crucial during a seizure. Applying oxygen may be necessary after ensuring a patent airway, while administering an anticonvulsant is not within the nurse's scope of practice during an acute seizure. Notifying the provider can be done after ensuring the client's immediate safety.

5. A nurse is assessing a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?

• A. Nausea
• B. Decreased heart rate
• C. Weight gain
• D. Fever

Correct answer: A

Rationale: Nausea is a common symptom of intolerance to enteral feedings. When a client experiences nausea during enteral feeding, it can indicate issues such as feeding tube placement problems, formula intolerance, or gastroparesis. Nausea can lead to vomiting and further complications if not addressed promptly. Decreased heart rate, weight gain, and fever are not typically associated with intolerance to enteral feedings and would not be the primary indicators for this situation.

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