Nursing Elites

1. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?

• A. Cancer of any kind
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

2. A nurse is caring for a client with a pressure ulcer. Which of the following interventions is most appropriate?

• A. Administer a protein supplement
• B. Increase protein intake in the client's diet
• C. Increase IV fluid intake to improve hydration
• D. Cleanse the wound from the center outwards

Correct answer: D

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps prevent infection and promotes healing by ensuring that any contaminants are moved away from the center of the wound. Administering a protein supplement (choice A) or increasing protein intake in the client's diet (choice B) may be beneficial for overall healing but are not the most appropriate interventions specifically for wound care. Increasing IV fluid intake (choice C) is important for hydration but is not the most appropriate intervention for managing a pressure ulcer.

3. A nurse is reinforcing teaching about wound care for a client who has a wound requiring irrigation. What is an important instruction?

• A. Wear sterile gloves when applying a new dressing
• B. Cleanse the wound from the center outwards
• C. Keep the wound dry between dressing changes
• D. Apply an antimicrobial ointment to the wound

Correct answer: B

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps reduce the risk of contamination by pushing debris away from the wound. Option A, wearing sterile gloves, is important for infection control but not specifically related to wound irrigation. Option C, keeping the wound dry, is not suitable for wound irrigation, which often involves using solutions to clean the wound. Option D, applying an antimicrobial ointment, is not typically done during wound irrigation as the focus is on cleansing the wound.

4. 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.

5. A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?

• A. Irrigate the wound with normal saline.
• B. Apply a wet-to-dry gauze dressing.
• C. Use a cotton ball to cleanse the wound.
• D. Administer an analgesic after the dressing change.

Correct answer: A

Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.

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