Nursing Elites

1. The client with diabetes is being taught about the importance of foot care. Which statement by the client indicates a need for further teaching?

• A. ''I will inspect my feet daily for any cuts or blisters.''
• B. ''I will soak my feet in warm water every day.''
• C. ''I will wear shoes that fit properly to avoid injury.''
• D. ''I will avoid walking barefoot to protect my feet.''

Correct answer: B

Rationale: Choice B is the correct answer because soaking feet daily can lead to skin breakdown, making it inappropriate for clients with diabetes. Inspecting feet daily for cuts or blisters (Choice A), wearing properly fitting shoes (Choice C), and avoiding walking barefoot (Choice D) are all appropriate measures to maintain foot health for clients with diabetes.

2. After morning dressing changes, a male client with paraplegia contaminates his ischial decubiti dressing with diarrheal stool. What is the best activity for the nurse to assign to the unlicensed assistive personnel (UAP)?

• A. Identify the need for additional supplies for an extra dressing change
• B. Provide perianal care and collect clean linens for the dressing change
• C. Document the diarrhea that necessitates an additional dressing change
• D. Position the client for access to the decubiti sites and remove dressings

Correct answer: B

Rationale: The best activity for the nurse to assign to the unlicensed assistive personnel (UAP) in this situation is to provide perianal care and collect clean linens for the dressing change. This task is crucial to maintain proper hygiene, prevent infection, and promote healing in the areas affected by decubiti. Choice A is not the priority as addressing the contamination and ensuring hygiene is more critical. Choice C is not the immediate concern and does not address the current situation. Choice D involves direct client care tasks that should be handled by licensed nursing staff.

3. A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?

• A. Instruct the client to sit or lie down
• B. Monitor blood pressure and pulse
• C. Administer an anti-dizziness medication
• D. Increase fluid intake

Correct answer: B

Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.

4. A client with a history of chronic heart failure is admitted with symptoms of dyspnea and fatigue. What initial intervention should the nurse prepare to implement?

• A. Administration of IV diuretics
• B. Oxygen therapy
• C. Bed rest
• D. Dietary consultation

Correct answer: B

Rationale: The correct initial intervention for a client with chronic heart failure presenting with dyspnea and fatigue is oxygen therapy. Oxygen therapy can help relieve dyspnea and improve oxygen saturation levels, which are crucial in managing heart failure exacerbations. Administering IV diuretics may be necessary later to address fluid overload, but oxygen therapy takes precedence in addressing the immediate respiratory distress. Bed rest and dietary consultation are important aspects of care for heart failure patients, but in this scenario, oxygen therapy is the priority to improve the client's respiratory status.

5. What action should the nurse implement in caring for a client following an electroencephalogram (EEG)?

• A. Monitor the client's vital signs every 4 hours
• B. Assess the client's lower extremities for sensation
• C. Instruct the client to maintain bed rest
• D. Wash any paste from the client's hair and scalp

Correct answer: D

Rationale: The correct action the nurse should implement after an EEG is to wash any paste from the client's hair and scalp. This is crucial to prevent irritation and infection at the EEG site. Monitoring vital signs every 4 hours is not specifically indicated after an EEG. Assessing the client's lower extremities for sensation is unrelated to caring for a client post-EEG. While rest may be recommended after the procedure, there is no standard requirement for a specific duration of bed rest.

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