Nursing Elites

1. The healthcare provider 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 healthcare provider 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: The correct technique to cleanse a wound when the prescription does not specify a cleaning method is to irrigate the wound with sterile normal saline. Sterile normal saline is the preferred solution for wound cleaning as it is gentle and does not damage healthy tissues. It helps in removing debris and maintaining a moist environment conducive to healing. Povidone-iodine solution and hydrogen peroxide can be harsh on tissues and delay wound healing. Removing eschar with a wet-to-dry dressing is a mechanical debridement method and should not be done without proper assessment and healthcare provider's order.

2. An elderly patient has been living in a nursing home for several years. The nursing staff has begun to notice a change in her behavior. All of the following are symptoms of depression except:

• A. Changes in sleep patterns
• B. Changes in eating patterns with weight loss
• C. Excessive fatigue and increased concern with bodily functions
• D. Hyperorality

Correct answer: D

Rationale: Hyperorality is not typically a symptom of depression. Symptoms of depression often include changes in sleep patterns, eating patterns with weight loss, and excessive fatigue. Hyperorality, which refers to the tendency to examine, chew, or ingest non-nutritive substances, is not a common symptom associated with depression.

3. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?

• A. Encourage the client to increase ambulation in the room.
• B. Offer the client a high-carbohydrate snack for energy.
• C. Force fluids to thin the client's pulmonary secretions.
• D. Determine if pain is causing the client's tachypnea.

Correct answer: D

Rationale: An increased respiratory rate can be a sign of various issues postoperatively, including pain. Assessing and managing pain is crucial as it can lead to tachypnea. Pain, anxiety, and fluid accumulation in the lungs can all contribute to an increased respiratory rate. Therefore, determining if pain is causing the tachypnea is the most important intervention to address the underlying cause. Encouraging ambulation, offering snacks, or forcing fluids are not the priority in this situation as pain assessment takes precedence in managing the increased respiratory rate.

4. A client with a suspected kidney infection is admitted to the hospital for observation. Which action should the nurse implement to assess the client’s kidney function?

• A. Monitor the client’s urine output
• B. Check for abdominal tenderness
• C. Evaluate the client’s fluid intake
• D. Inspect the client’s skin for edema

Correct answer: A

Rationale: Monitoring urine output is the most direct way to assess kidney function as it provides crucial information about the kidneys’ ability to filter waste and produce urine. Changes in urine output can indicate potential issues with kidney function, such as decreased filtration or impaired excretion of waste products.

5. The client is receiving discharge teaching for a new diagnosis of asthma. Which statement by the client indicates a need for further teaching?

• A. I should use my inhaler as soon as I begin to feel short of breath.
• B. I should avoid using my inhaler unless I am having an asthma attack.
• C. I should use my inhaler 30 minutes before exercise.
• D. I should rinse my mouth after using my inhaler.

Correct answer: B

Rationale: The statement 'I should avoid using my inhaler unless I am having an asthma attack' (B) indicates a need for further teaching. It is important for clients to use their inhaler as prescribed, which may include regular use to prevent asthma attacks. Choice A is correct because using the inhaler when feeling short of breath can help manage asthma symptoms. Choice C is also correct as using the inhaler before exercise can prevent exercise-induced symptoms. Choice D is correct as rinsing the mouth after using the inhaler helps prevent oral thrush, a potential side effect of inhaled corticosteroids. Therefore, option B is the most concerning statement that needs clarification.

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