Nursing Elites

1. What are the steps in managing a patient with a pressure ulcer?

• A. Clean the wound and apply a hydrocolloid dressing
• B. Debride necrotic tissue and apply antibiotics
• C. Apply an alginate dressing and elevate the affected area
• D. Use moisture-retentive dressings and reposition frequently

Correct answer: A

Rationale: The correct answer is A: Clean the wound and apply a hydrocolloid dressing. This step is crucial in managing a pressure ulcer as it helps protect the ulcer from infection and promotes healing by creating a moist environment conducive to tissue repair. Choice B, debriding necrotic tissue and applying antibiotics, is more suitable for managing infected pressure ulcers but not as the initial step. Choice C, applying an alginate dressing and elevating the affected area, may be part of the management but is not the initial step. Choice D, using moisture-retentive dressings and repositioning frequently, is important for prevention but not the first step in managing an existing pressure ulcer.

2. A client undergoing radiation therapy is being taught about skin care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will use a heating pad to soothe the skin
• B. I will avoid using perfumed lotions on the treated area
• C. I will apply cold compresses to the area
• D. I will scrub the area daily with soap and water

Correct answer: B

Rationale: The correct answer is B because avoiding perfumed lotions is important to prevent skin irritation after radiation therapy. Using a heating pad (A) can further damage the skin, applying cold compresses (C) may not be recommended, and scrubbing the area daily with soap and water (D) can be too harsh on the skin, leading to further irritation and damage.

3. The nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

• A. Request an occupational therapy consult to determine the need for assistive devices
• B. Assign assistive personnel to perform self-care tasks for the client
• C. Instruct the client to focus on gradually resuming self-care tasks
• D. Ask the client if a family member is available to assist with his care

Correct answer: C

Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence while managing fatigue. This approach encourages the client to regain autonomy by engaging in self-care activities at their own pace. Requesting an occupational therapy consult (Choice A) may be beneficial but does not directly address the client's concern regarding fatigue and self-care. Assigning assistive personnel (Choice B) may hinder the client's independence by taking over tasks the client could potentially perform. Asking about family assistance (Choice D) does not empower the client to regain self-care abilities.

4. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

• A. Experiencing delusions.
• B. Male gender.
• C. Previous violent behavior.
• D. A history of being in prison.

Correct answer: C

Rationale: The correct answer is C: Previous violent behavior. This is considered the best predictor of future violent actions as individuals who have a history of violent behavior are more likely to engage in violent acts again. Option A, experiencing delusions, although it can impact behavior, is not as strong of a predictor as past violent behavior. Option B, male gender, is a demographic factor but not as specific or predictive as a history of violence. Option D, a history of being in prison, may indicate past behavior but is not directly linked to future violent actions as a known history of violence.

5. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

• A. Monitor for changes in level of consciousness
• B. Check for pupil dilation
• C. Assess for bradycardia
• D. Monitor for vomiting

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

Similar Questions