Nursing Elites

1. What are the steps in providing perineal care to a patient?

• A. Clean the perineal area with soap and water
• B. Use antiseptic wipes to prevent infection
• C. Pat the area dry after cleaning
• D. Always use gloves when performing care

Correct answer: A

Rationale: The correct answer is A: Clean the perineal area with soap and water. This step is essential in preventing infection and promoting hygiene. Using antiseptic wipes (choice B) is not a standard practice for perineal care; soap and water are preferred. While patting the area dry after cleaning (choice C) is important, the initial step of cleaning with soap and water is crucial. Using gloves (choice D) is a good practice to prevent the spread of infection, but it is not the initial step in providing perineal care.

2. A client with hypertension is asking for lifestyle changes. What should the nurse recommend?

• A. Increase sodium intake to manage blood pressure
• B. Reduce caffeine and alcohol consumption
• C. Encourage the client to increase protein intake
• D. Increase intake of fruits and vegetables

Correct answer: B

Rationale: The correct answer is B: Reduce caffeine and alcohol consumption. This recommendation is crucial for managing hypertension as excessive caffeine and alcohol intake can elevate blood pressure. By reducing these stimulants, the client can help regulate their blood pressure levels. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is contraindicated in hypertension as it can lead to fluid retention and worsen blood pressure. Encouraging increased protein intake (Choice C) and increasing intake of fruits and vegetables (Choice D) are generally healthy dietary suggestions but not specifically targeted at managing hypertension.

3. What is the most appropriate action for a healthcare provider to take when a patient is experiencing a seizure?

• A. Protect the patient's head
• B. Restrain the patient's movements
• C. Insert an airway
• D. Give the patient water

Correct answer: A

Rationale: During a seizure, the most appropriate action for a healthcare provider is to protect the patient's head. This helps prevent injury, especially considering the involuntary movements and potential thrashing associated with seizures. Restraint should be avoided as it can lead to further injury or distress for the patient. Inserting an airway is not recommended during an active seizure as the patient's airway may not be obstructed, and it could pose a risk of injury. Giving the patient water during a seizure is also not advisable as there is a risk of aspiration. Therefore, the priority is to ensure the patient's safety by protecting their head.

4. Which of the following actions should the nurse take for a client who has been diagnosed with dementia and is at risk for falls?

• A. Maintain the client's bed in the lowest position
• B. Use a bed exit alarm system
• C. Assist the client with ambulation every hour
• D. Raise all 4 side rails for safety

Correct answer: B

Rationale: The correct answer is B: "Use a bed exit alarm system." For a client with dementia at risk for falls, a bed exit alarm system is beneficial as it alerts staff when the client is trying to get up, helping to reduce fall risks. Choice A, maintaining the client's bed in the lowest position, may not prevent falls as effectively as an alarm system. Choice C, assisting the client with ambulation every hour, may not be feasible and could disrupt the client's rest. Choice D, raising all 4 side rails for safety, can lead to restraint issues and is not recommended as a routine fall prevention measure.

5. A healthcare professional is reviewing the medical history of a client with dementia. Which of the following findings should be addressed immediately?

• A. Frequent episodes of wandering at night
• B. Restlessness and agitation
• C. Mild confusion during the day
• D. Incontinence

Correct answer: B

Rationale: Restlessness and agitation in clients with dementia should be addressed immediately as they can indicate underlying causes such as pain, discomfort, or unmet needs. Addressing these symptoms promptly can help prevent the escalation of behavioral issues and improve the client's quality of life. While frequent episodes of wandering at night, mild confusion during the day, and incontinence are also important issues to address in clients with dementia, restlessness and agitation usually require immediate attention to ensure the safety and well-being of the client.

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