Nursing Elites

1. What is the most important nursing intervention when caring for a patient with a wound?

• A. Apply an occlusive dressing over the wound.
• B. Clean the wound with normal saline.
• C. Administer antibiotics as prescribed.
• D. Reassess the wound every 4 hours for changes.

Correct answer: B

Rationale: The most important nursing intervention when caring for a patient with a wound is to clean the wound with normal saline. This is crucial for preventing infection and promoting healing. Applying an occlusive dressing (Choice A) can be important but should come after cleaning the wound. Administering antibiotics (Choice C) is not the first-line intervention for all wounds and should be based on the healthcare provider's prescription. Reassessing the wound (Choice D) is essential but not the most important initial intervention.

2. After signing an informed consent form, a client states, 'I have changed my mind and do not want to have the procedure.' Which of the following actions should the nurse take?

• A. Suggest that family members discuss the importance of the surgery with the client
• B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure
• C. Document the risks of refusing the procedure in the client's medical record
• D. Discuss the benefits of the procedure with the client

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to notify the surgeon that the client wishes to withdraw informed consent for the procedure. This ensures that the client's right to refuse treatment is respected. Choice A is incorrect because involving family members in this decision could violate the client's autonomy. Choice C is incorrect as it does not address the immediate need to respect the client's decision. Choice D is also incorrect as the client has clearly stated their refusal of the procedure.

3. A nurse is caring for a patient postoperatively after a thyroidectomy. Which of the following findings should be reported immediately?

• A. Hoarseness
• B. Difficulty swallowing
• C. Numbness in the fingers
• D. Tingling around the mouth

Correct answer: D

Rationale: Tingling around the mouth should be reported immediately as it may indicate hypocalcemia, a serious complication resulting from accidental removal or damage to the parathyroid glands during thyroidectomy. Hoarseness and difficulty swallowing are common post-thyroidectomy symptoms related to the surgery itself and the manipulation of the vocal cords and nearby structures. Numbness in the fingers is not typically associated with immediate serious complications of a thyroidectomy.

4. A client with pneumonia is receiving oxygen therapy. Which of the following oxygen delivery devices should be used to deliver a precise oxygen concentration?

• A. Nasal cannula
• B. Simple face mask
• C. Venturi mask
• D. Non-rebreather mask

Correct answer: C

Rationale: A Venturi mask should be used to deliver a precise oxygen concentration to a client with pneumonia. Venturi masks are designed to deliver a specific oxygen concentration by mixing oxygen with room air in a precise ratio. This device is ideal for patients who require accurate oxygen delivery, such as those with chronic lung diseases. Nasal cannulas deliver a lower concentration of oxygen and are more suitable for patients with mild respiratory issues. Simple face masks and non-rebreather masks do not provide as precise control over the oxygen concentration as a Venturi mask.

5. How should a healthcare professional position a patient to reduce the risk of pressure ulcers?

• A. Position the patient in the supine position for long periods.
• B. Use pillows to support bony prominences.
• C. Turn the patient every 4 hours.
• D. Place the patient on an alternating pressure mattress.

Correct answer: B

Rationale: Correctly positioning a patient to reduce the risk of pressure ulcers involves using pillows to support bony prominences. This helps to relieve pressure from vulnerable areas and prevent the development of pressure ulcers. Choice A is incorrect because keeping a patient in the supine position for extended periods can increase the risk of pressure ulcers. Choice C is incorrect as turning the patient every 2 hours, rather than every 4 hours, is recommended to prevent pressure ulcers. Choice D is not the best option mentioned for positioning a patient to reduce pressure ulcer risk; although alternating pressure mattresses can be beneficial, using pillows for support is a more direct and commonly used method.

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