Nursing Elites

1. A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching?

• A. I can place an oval corn pad over toes that have corns as long as I remove the pad weekly
• B. I should soak my feet in warm water daily to soften corns and calluses
• C. I can apply lotion to soften calluses as long as I don’t put lotion between my toes
• D. I should use an over the counter liquid medication to remove corns

Correct answer: C

Rationale: Applying lotion to the feet, avoiding between toes, is correct; over-the-counter treatments and soaking are not recommended.

2. The nurse is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse use to cleanse the pressure ulcer?

• A. Lightly coat the wound with povidone-iodine solution
• B. Irrigate the wound with sterile normal saline
• C. Flush the wound with sterile hydrogen peroxide
• D. Remove the eschar with a wet-to-dry dressing

Correct answer: B

Rationale: Irrigating the wound with sterile normal saline is the correct technique for cleansing a wound when the prescription does not specify a cleaning method. Sterile normal saline is a standard and safe solution that helps to remove debris and promote healing without damaging healthy tissue. Choice A, using povidone-iodine solution, can be cytotoxic and delay wound healing. Choice C, using hydrogen peroxide, can be cytotoxic, cause tissue damage, and delay wound healing. Choice D, using wet-to-dry dressing to remove eschar, is an outdated and non-selective method that can cause trauma to the wound bed and delay healing. Therefore, choice B is the best option for wound cleansing in this scenario.

3. A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?

• A. Collaborating with providers to perform obesity screenings during routine office visits.
• B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity.
• C. Providing specialized intraoperative training in surgical treatments for obesity.
• D. Educating acute care nurses about postoperative complications related to obesity.

Correct answer: A

Rationale: The correct answer is A: Collaborating with providers to perform obesity screenings during routine office visits. This is a primary health care strategy as it focuses on prevention and early detection, which are key components of managing obesity. Screening during routine visits allows for timely identification of obesity and related health risks, enabling early intervention. Choices B, C, and D do not align with primary health care strategies for obesity. Ensuring availability of specialized beds, providing intraoperative training, and educating about postoperative complications are more focused on secondary and tertiary levels of care, rather than primary prevention and early detection.

4. The nurse is caring for a 4-year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately?

• A. Vomiting of dark emesis
• B. Complaints of throat pain
• C. Apical heart rate of 110
• D. Increased restlessness

Correct answer: D

Rationale: Increased restlessness must be reported immediately as it may indicate bleeding or other complications post-tonsillectomy and adenoidectomy. This could be a sign of a developing issue that requires urgent intervention. Vomiting of dark emesis, complaints of throat pain, and an apical heart rate of 110 are important to monitor but do not indicate an immediate need for reporting as compared to the potential seriousness of increased restlessness in this scenario.

5. The female is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?

• A. Should be postponed because it may cause embarrassment.
• B. Should be unnecessary because the patient is uncircumcised.
• C. Should be done by the patient.
• D. Should be done by the nurse.

Correct answer: C

Rationale: Perineal care should be encouraged to be done by the patient if they are capable of performing self-care. In this scenario, the patient is not ambulatory and has full function of all extremities, indicating that the patient can independently perform perineal care. Encouraging self-care promotes independence and maintains the patient's dignity. Postponing perineal care (Choice A) is incorrect because it is essential for hygiene. Choice B is incorrect as perineal care is necessary for all patients regardless of circumcision status. Choice D is incorrect as the patient is capable of performing the care independently, and promoting self-care is a priority in nursing practice.

Similar Questions