Nursing Elites

1. Which nursing action is a priority when managing a client with a wound infection?

• A. Change the wound dressing every 24 hours
• B. Perform a wound culture before administering antibiotics
• C. Cleanse the wound with alcohol-based solutions
• D. Apply a wet-to-dry dressing to the wound

Correct answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial when managing a client with a wound infection. This step helps identify the specific pathogens causing the infection, allowing for the prescription of the most effective antibiotics. Changing the wound dressing every 24 hours (Choice A) is important for wound care but not the priority when an infection is present. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and may delay wound healing. Applying a wet-to-dry dressing (Choice D) is not recommended for infected wounds as it can cause trauma to the wound bed during dressing changes.

2. What is the best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care?

• A. Instruct the client to rest completely and avoid all self-care tasks
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to complete all self-care tasks
• D. Ask the client's family to assist with self-care tasks

Correct answer: B

Rationale: The best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care is to encourage the client to gradually resume self-care tasks with frequent rest periods. This approach helps the client regain independence while managing fatigue effectively. Choice A is incorrect because complete rest without any self-care tasks may hinder recovery and independence. Choice C is not the best option as it does not promote the client's independence. Choice D, while involving family support, does not empower the client to regain self-care abilities.

3. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?

• A. Total bilirubin.
• B. Urine ketones.
• C. Serum potassium.
• D. Platelet count.

Correct answer: C

Rationale: The correct answer is C: Serum potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Therefore, the nurse should monitor the client's serum potassium levels to prevent hyperkalemia, which can be a potential side effect of spironolactone. Monitoring total bilirubin levels (A) is not specifically required for clients taking spironolactone. Urine ketones (B) are not directly influenced by spironolactone use. Platelet count (D) is not typically monitored in clients taking spironolactone.

4. A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?

• A. Do not press the button during baby's movements
• B. You should depress the button when you feel your baby move
• C. Press the button only during contractions
• D. Do not eat before the test

Correct answer: B

Rationale: The correct answer is B because the client should press the button when feeling fetal movement to track the baby's activity. Choice A is incorrect because the client should press the button during movements. Choice C is incorrect as the button should be pressed during fetal movements, not contractions. Choice D is irrelevant to the instructions for the nonstress test.

5. How should a healthcare provider manage a patient with Type 1 diabetes?

• A. Administer insulin and monitor blood glucose levels
• B. Provide a low-carbohydrate diet and oral hypoglycemics
• C. Administer oral hypoglycemics and provide dietary education
• D. Provide a high-protein diet and insulin injections

Correct answer: A

Rationale: Type 1 diabetes is managed with insulin administration and regular blood glucose monitoring. Choice A is correct because administering insulin is essential in Type 1 diabetes management to help regulate blood glucose levels. Choices B, C, and D are incorrect because Type 1 diabetes requires insulin therapy as the primary treatment, not oral hypoglycemics or dietary modifications like low-carbohydrate or high-protein diets. Monitoring blood glucose levels is crucial in adjusting insulin doses and ensuring optimal management of the condition.

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