Nursing Elites

1. The nurse is teaching a client with newly diagnosed type 1 diabetes about insulin administration. Which statement by the client indicates a need for further teaching?

• A. I will rotate my injection sites to avoid lipodystrophy.
• B. I will check my blood sugar before meals and at bedtime.
• C. I will use the same needle for 3 days if I keep it clean.
• D. I will keep my insulin refrigerated until I need it.

Correct answer: C

Rationale: The correct answer is C because insulin needles should be disposed of after a single use to prevent infection. Reusing the same needle for three days can lead to infection and is not a safe practice. Choices A, B, and D demonstrate good understanding of insulin administration and diabetes management, so they do not indicate a need for further teaching.

2. The healthcare provider is preparing a client with deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?

• A. Client should be NPO prior to the test
• B. Client should receive a sedative medication before the test
• C. Discontinue anticoagulant therapy before the test
• D. No special preparation is necessary

Correct answer: D

Rationale: No special preparation is required for a Venous Doppler evaluation. Option A is incorrect because there is no need for the client to be NPO (nothing by mouth) before this test. Option B is incorrect as sedative medication is not typically administered for a Venous Doppler evaluation. Option C is incorrect as discontinuing anticoagulant therapy before the test may not be safe for a client with DVT, as it could increase the risk of developing a blood clot. Therefore, the correct answer is D.

3. A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia?

• A. Linear clusters of vesicles on the right shoulder.
• B. Purulent drainage from both eyes.
• C. Decreased white blood cell count.
• D. Report of continued pain following resolution of the rash.

Correct answer: D

Rationale: The correct answer is D: Report of continued pain following resolution of the rash. Postherpetic neuralgia is a complication of herpes zoster characterized by persistent pain that continues even after the rash has resolved. This pain can be severe and debilitating, affecting the quality of life of the individual. Choices A, B, and C are incorrect because linear clusters of vesicles on the right shoulder would suggest an active herpes zoster outbreak, purulent drainage from both eyes would indicate an eye infection unrelated to postherpetic neuralgia, and a decreased white blood cell count is not typically associated with postherpetic neuralgia.

4. The nurse 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 nurse 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: Irrigating the wound with sterile normal saline is the correct technique for cleansing a wound when the prescription does not specify a cleaning method. Sterile normal saline is a standard and safe solution that helps to remove debris and promote healing without damaging healthy tissue. Choice A, using povidone-iodine solution, can be cytotoxic and delay wound healing. Choice C, using hydrogen peroxide, can be cytotoxic, cause tissue damage, and delay wound healing. Choice D, using wet-to-dry dressing to remove eschar, is an outdated and non-selective method that can cause trauma to the wound bed and delay healing. Therefore, choice B is the best option for wound cleansing in this scenario.

5. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glascow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glascow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.

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