Nursing Elites

1. What are the nursing interventions for a patient with a pressure ulcer?

• A. Clean the wound and apply a hydrocolloid dressing
• B. Provide a high-protein diet and ensure bed rest
• C. Monitor for signs of infection and provide antibiotics
• D. Provide a low-sodium diet and monitor for fluid retention

Correct answer: A

Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.

2. What are the nursing interventions for a patient with fluid volume overload?

• A. Restrict fluid intake
• B. Monitor intake and output
• C. Administer diuretics as prescribed
• D. Elevate the head of the bed

Correct answer: A

Rationale: The correct nursing intervention for a patient with fluid volume overload is to restrict fluid intake. This helps to prevent further fluid accumulation in the body. Monitoring intake and output (choice B) is important to assess the patient's fluid balance but is not a direct intervention to address fluid volume overload. Administering diuretics as prescribed (choice C) is a medical intervention that may be ordered by a healthcare provider but should not be assumed as a nursing intervention without a prescription. Elevating the head of the bed (choice D) is a measure commonly used for patients with respiratory distress or to prevent aspiration but is not a direct intervention for fluid volume overload.

3. A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?

• A. Bright red bleeding
• B. Burning with urination
• C. Headache
• D. Heavy lochia flow

Correct answer: B

Rationale: The correct answer is B: 'Burning with urination.' Burning with urination can indicate a urinary tract infection postpartum, which requires immediate attention to prevent complications. Bright red bleeding and heavy lochia flow are expected findings in the early postpartum period as the uterus continues to contract and expel lochia. A headache alone is not uncommon postpartum and is often attributed to hormonal changes, dehydration, or fatigue, and can be managed with adequate rest, hydration, and pain relief. Therefore, the priority here is to address the potential infection indicated by burning with urination.

4. How should a healthcare provider care for a patient with a nasogastric (NG) tube?

• A. Check tube placement and assess for signs of aspiration
• B. Flush the tube with water regularly to maintain patency
• C. Monitor for bowel sounds and administer medications
• D. Administer medications through the tube

Correct answer: A

Rationale: When caring for a patient with a nasogastric (NG) tube, it is crucial to check the tube placement and assess for signs of aspiration. This ensures that the tube is correctly positioned and that the patient is not at risk of complications such as aspiration pneumonia. Choice B is incorrect as flushing the tube with water regularly is not a standard practice and may not be appropriate for all patients. Choice C is incorrect as monitoring for bowel sounds is not directly related to NG tube care, and administering medications is not the primary focus of caring for the tube itself. Choice D is incorrect because administering medications through the NG tube is a specific action that may be taken based on a healthcare provider's order, not a general care guideline for the NG tube.

5. A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

• A. Position the drainage bag below the bladder
• B. Wipe the drainage port after emptying
• C. Insert the catheter using sterile technique
• D. Avoid cleansing the urinary meatus

Correct answer: B

Rationale: The correct answer is to wipe the drainage port after emptying. This action helps reduce the risk of infection by maintaining cleanliness. Positioning the drainage bag below the bladder (choice A) is incorrect as it should be positioned below the level of the bladder to prevent backflow of urine. Inserting the catheter using sterile technique (choice C) is not necessary for routine emptying of the drainage bag. Avoiding cleansing the urinary meatus (choice D) is incorrect as proper hygiene should be maintained to prevent infections.

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