Nursing Elites

1. What is the primary action when caring for a patient with a stage 3 pressure ulcer?

• A. Apply a hydrocolloid dressing
• B. Provide wound debridement
• C. Change the dressing daily
• D. Apply moist gauze to the ulcer

Correct answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. This type of dressing helps maintain a moist environment that is conducive to healing in stage 3 pressure ulcers. Providing wound debridement (choice B) is more suitable for higher stages of pressure ulcers where there is necrotic tissue. Changing the dressing daily (choice C) may be necessary but is not the primary action for a stage 3 pressure ulcer. Applying moist gauze (choice D) is not the recommended approach as it does not provide the same benefits as a hydrocolloid dressing.

2. A nurse is preparing to administer vancomycin IV to a client. Which of the following actions should the nurse take?

• A. Administer the medication over 30 minutes.
• B. Monitor the client for a decrease in blood pressure during administration.
• C. Assess the IV site for infiltration during administration.
• D. Premedicate the client with an antiemetic prior to administration.

Correct answer: C

Rationale: The correct action the nurse should take when administering vancomycin IV is to assess the IV site for infiltration during administration. Vancomycin is known to cause tissue damage if it infiltrates, making close monitoring crucial. Administering the medication over 30 minutes (Choice A) is a common practice but not the priority in preventing infiltration. Monitoring for a decrease in blood pressure (Choice B) is not directly related to vancomycin administration. Premedicating with an antiemetic (Choice D) is not typically required for vancomycin administration.

3. A nurse is planning care for a client with thrombocytopenia. Which action should be included?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving the client raw vegetables.

Correct answer: C

Rationale: The correct action to include in the care plan for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent straining during bowel movements, reducing the risk of bleeding episodes. Encouraging the client to floss daily (choice A) is important for oral hygiene but is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (choice B) is more relevant for clients with neutropenia to reduce the risk of infection. Avoiding serving the client raw vegetables (choice D) is important for clients with compromised immune systems but is not specifically related to thrombocytopenia.

4. How should a healthcare professional manage a patient with non-compliance to hypertension medication?

• A. Provide education on medication
• B. Refer the patient to a specialist
• C. Discontinue the medication
• D. Reassess the patient in 6 months

Correct answer: A

Rationale: Providing education on medication is crucial when managing a patient with non-compliance to hypertension medication. By educating the patient on the importance of adherence, potential side effects, and the impact of uncontrolled hypertension, healthcare professionals can help improve the patient's understanding and compliance. Referring the patient to a specialist (Choice B) may be necessary in some cases but should not be the first step. Discontinuing the medication (Choice C) without exploring reasons for non-compliance and providing education can worsen the patient's condition. Reassessing the patient in 6 months (Choice D) is important but should be accompanied by interventions to address non-compliance in the interim.

5. 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 the best predictor of future violence as individuals who have a history of violent behavior are more likely to engage in violent acts in the future. While experiencing delusions and being male may contribute to an increased risk of violence in certain situations, they are not as strong predictors as a history of violence. Similarly, having a history of being in prison may indicate a higher likelihood of violence, but it is not as directly linked to future violent behavior as previous violent actions.

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