Nursing Elites

1. A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect?

• A. Flushed skin
• B. Bradycardia
• C. Mental confusion
• D. Hypotension

Correct answer: C

Rationale: The correct answer is C: Mental confusion. In this scenario, the client's high fever and pneumonia diagnosis indicate an infection. Infections, especially in older adults, can lead to mental confusion due to the body's systemic response to the infection. Flushed skin (choice A) is more commonly associated with fever but does not specifically relate to the client's condition. Bradycardia (choice B) and hypotension (choice D) are less likely findings in a client with pneumonia and a high fever; instead, tachycardia and increased blood pressure are more commonly seen in response to infection.

2. A client with a fractured femur is in Buck's traction. The nurse should assess for which of the following complications?

• A. Foot drop
• B. Urinary retention
• C. Constipation
• D. Muscle spasms

Correct answer: A

Rationale: Corrected Rationale: Foot drop is a potential complication of prolonged immobility and improper positioning in traction. In Buck's traction, the lower extremity is suspended to immobilize and align the fractured femur. Prolonged suspension of the leg in traction can lead to nerve damage, specifically to the common peroneal nerve, resulting in foot drop. Urinary retention, constipation, and muscle spasms are not directly associated with Buck's traction and a fractured femur.

3. Which of the following is an example of a positive outcome for one of the Leading Health Indicators of Healthy People 2020?

• A. A community has adopted a no smoking policy.
• B. A rural community has a public transportation system.
• C. The high school dropout rate has decreased by 15%.
• D. A county has decreased its divorce rate by 10%.

Correct answer: A

Rationale: The correct answer is A. A community adopting a no smoking policy is a positive outcome for the Leading Health Indicators of Healthy People 2020 as it promotes a healthier environment by reducing exposure to secondhand smoke and decreasing smoking-related illnesses. Choices B, C, and D do not directly align with the goals of the Leading Health Indicators. While public transportation and reduced dropout rates are beneficial for community well-being, they are not specific examples of Leading Health Indicators. Decreasing divorce rates, while potentially beneficial for family stability, is not a focus area of the Leading Health Indicators.

4. A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). The nurse should monitor the client for which of the following laboratory values?

• A. Prothrombin time (PT)
• B. Serum potassium
• C. Blood urea nitrogen (BUN)
• D. White blood cell count (WBC)

Correct answer: A

Rationale: The correct answer is A: Prothrombin time (PT). Prothrombin time is monitored to assess the effectiveness of warfarin therapy. Warfarin is an anticoagulant medication that works by inhibiting the synthesis of vitamin K-dependent clotting factors, including factors II, VII, IX, and X. Monitoring the PT helps ensure that the client's blood is clotting within the desired therapeutic range to prevent complications such as recurrent DVT or excessive bleeding. Choices B, C, and D are incorrect because serum potassium, blood urea nitrogen, and white blood cell count are not directly related to monitoring warfarin therapy in a client with a history of DVT.

5. While assessing an Rh-positive newborn whose mother is Rh-negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?

• A. Jaundice evident at 26 hours
• B. Hematocrit of 55%
• C. Serum bilirubin of 12 mg/dL
• D. Positive Coombs test

Correct answer: C

Rationale: A serum bilirubin level of 12 mg/dL in a newborn is concerning and can indicate a significant risk of hyperbilirubinemia, which requires immediate medical intervention to prevent complications like kernicterus. Jaundice at 26 hours (Choice A) is a symptom, not a laboratory result, and needs monitoring but not an immediate report. Hematocrit of 55% (Choice B) may be elevated but is not indicative of hyperbilirubinemia. A positive Coombs test (Choice D) indicates the presence of antibodies on the newborn's red blood cells but does not directly correlate with the risk of hyperbilirubinemia.

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