Nursing Elites

1. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

• A. Ensure that the bed linen is always dry
• B. Frequently check the bed for wetness and keep it dry
• C. Place a rubber sheet under the client's buttocks
• D. Keep the patient clean and dry

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

2. A patient with an ileostomy is suffering from frequent diarrhea. The clinician should advise the patient to increase his intake of what food to thicken stool output?

• A. celery
• B. salad greens
• C. potatoes
• D. dried beans and peas

Correct answer: C

Rationale: Potatoes are starchy and can help thicken stool output, making them beneficial for patients with an ileostomy experiencing diarrhea.

3. While on Bryant’s traction, which of these observations of Graciela and her traction apparatus would indicate a decrease in the effectiveness of her traction?

• A. Graciela’s buttocks are resting on the bed.
• B. The traction weights are hanging 10 inches above the floor.
• C. Graciela’s legs are suspended at a 90 degree angle to her trunk.
• D. The traction ropes move freely through the pulley.

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

4. You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:

• A. Take the blood pressure reading on both arms for comparison
• B. Listen to and identify the phases of Korotkoff sounds
• C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
• D. Observe procedures for infection control

Correct answer: B

Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.

5. A nurse is caring for a client who has a body mass index (BMI) of 30. Four weeks after nutritional counseling, which of the following evaluation findings indicates the plan of care was followed?

• A. BMI of 25
• B. Weight gain of 1.8 kg
• C. BMI of 33
• D. Weight loss of 2.7 kg

Correct answer: D

Rationale: A weight loss of 2.7 kg in four weeks indicates effective adherence to a nutritional plan aimed at reducing body mass index (BMI), moving towards a healthier weight. Choices A, B, and C are incorrect because a decrease in weight, as shown in choice D, is the desired outcome when managing a client with a BMI of 30 to reach a healthier range.

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