Nursing Elites

1. What is the nurse's priority intervention for a patient who has developed a pressure ulcer?

• A. Apply a dressing to the ulcer.
• B. Reposition the patient every 2 hours.
• C. Provide the patient with pain medication.
• D. Clean the ulcer with normal saline.

Correct answer: B

Rationale: The correct answer is to reposition the patient every 2 hours. Repositioning helps prevent the worsening of pressure ulcers by relieving pressure on affected areas and promoting blood circulation, which aids in healing. Applying a dressing (choice A) is important but not the priority compared to repositioning. Providing pain medication (choice C) is essential for comfort but does not address the root cause of the pressure ulcer. Cleaning the ulcer with normal saline (choice D) is part of wound care but does not take precedence over repositioning to prevent further tissue damage.

2. A client who has a new prescription for ferrous sulfate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should expect dark tarry stools.
• B. I should expect increased bruising.
• C. I will not get as many infections.
• D. I will expect the color of my urine to be amber.

Correct answer: A

Rationale: The correct answer is A. When taking ferrous sulfate, dark tarry stools can occur as a common side effect due to the iron content in the medication. This is a normal response to the medication and not a cause for concern. Choices B, C, and D are incorrect because increased bruising, reduced infections, and amber-colored urine are not expected side effects of ferrous sulfate.

3. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

• A. Self-report of pain
• B. Nonverbal behavior
• C. Severity of the condition
• D. Vital signs

Correct answer: A

Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.

4. A nurse is preparing an in-service about family violence for a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?

• A. Perpetrators of family-directed violence do not recognize their behavior as abnormal.
• B. Female clients who experience partner violence are at greater risk for chronic diseases.
• C. The victim's risk for homicide is greatest when they decide to leave the relationship.
• D. The level of violence increases over time in abusive relationships.

Correct answer: C

Rationale: The correct answer is C because the risk of homicide increases significantly when a victim decides to leave an abusive relationship. This is a crucial point to emphasize in educating healthcare professionals about family violence. Choice A is incorrect because perpetrators often do not acknowledge their behavior as abnormal. Choice B is incorrect as victims of partner violence are at greater risk for chronic, not acute, diseases. Choice D is incorrect as the level of violence tends to escalate rather than decrease over time in abusive relationships.

5. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notices clots in the client's urinary catheter and decreased urinary output. Which of the following actions should the nurse take?

• A. Administer an antispasmodic
• B. Irrigate the catheter with 0.9% sodium chloride irrigation
• C. Apply gentle manual pressure to the bladder
• D. Clamp the catheter tubing

Correct answer: B

Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation. This action helps clear the clots in the catheter and restore proper urine flow after a TURP. Administering an antispasmodic (Choice A) is not the appropriate action for clots in the catheter and decreased urinary output. Applying gentle manual pressure to the bladder (Choice C) or clamping the catheter tubing (Choice D) could potentially worsen the situation by causing bladder distention or preventing urine drainage.

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