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. The client reports still being unable to sleep a week after learning progressive muscle relaxation techniques. Which action should the nurse take first?

• A. Instruct the client to add regular exercise to the daily routine.
• B. Determine if the client has been keeping a sleep diary.
• C. Encourage the client to continue the routine until sleep is achieved.
• D. Ask the client to describe the routine currently followed.

Correct answer: D

Rationale: The nurse should first assess the client's adherence to the original instructions. By asking the client to describe the routine, the nurse can evaluate if the technique is being correctly implemented before considering further interventions. This choice is correct as it focuses on assessing the client's current practice. Option A is incorrect as adding regular exercise may not address the issue with the relaxation technique. Option B is incorrect as determining if the client has been keeping a sleep diary does not directly address the efficacy of the relaxation technique. Option C is incorrect as blindly encouraging the client to continue may not be the best approach without understanding how the technique is being practiced.

3. A client has a nursing diagnosis of 'Spiritual distress related to a loss of hope, secondary to impending death.' What intervention is best for the nurse to implement when caring for this client?

• A. Help the client accept the final stage of life.
• B. Assist and support the client in establishing short-term goals.
• C. Encourage the client to make future plans, even if they are unrealistic.
• D. Instruct the client's family to focus on positive aspects of the client's life.

Correct answer: B

Rationale: When a client is experiencing spiritual distress due to a loss of hope related to impending death, it is crucial for the nurse to assist and support the client in establishing short-term goals. This approach helps the client maintain hope and a sense of purpose, as achieving immediate goals can provide a sense of accomplishment and meaning. While acceptance of the final stage of life is important, helping the client set short-term goals is a more immediate and effective intervention in addressing spiritual distress. Encouraging the client to make future plans, especially if they are unrealistic, may not be beneficial as it could lead to further distress if those plans are unattainable. Instructing the client's family to focus on positive aspects of the client's life, though supportive, does not directly address the client's spiritual distress and loss of hope.

4. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?

• A. Removing the empty food tray from a client with a urinary catheter.
• B. Washing and combing the hair of a client with a fractured leg in traction.
• C. Administering oral medications to a cooperative client with a wound infection.
• D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Correct answer: D

Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.

5. The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?

• A. To promote oxygenation by removing secretions.
• B. To reduce the amount of air trapped in the lungs.
• C. To increase the amount of carbon dioxide exhaled.
• D. To slow the respiratory rate and improve air exchange.

Correct answer: C

Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A) and reducing air trapping (B) can be associated benefits to some extent, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics. Slowing the respiratory rate (D) is not the primary purpose of pursed-lip breathing.

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