Nursing Elites

1. A client who had a cerebral vascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?

• A. Risk for impaired tissue integrity related to impaired physical mobility
• B. Impaired skin integrity related to altered circulation and pressure
• C. Ineffective tissue perfusion related to inability to move self in bed
• D. Impaired physical mobility related to the left side paralysis

Correct answer: B

Rationale: The correct nursing diagnosis for this client is 'Impaired skin integrity related to altered circulation and pressure.' The client's Stage II pressure ulcer on the left hip is a clear indication of impaired skin integrity resulting from altered circulation and pressure due to immobility. Choice A is incorrect because the client already has a pressure ulcer, indicating an actual impairment rather than a risk. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this case. Choice D is incorrect as it focuses solely on the paralysis and not the actual skin integrity issue.

2. The nurse is assessing a client who has a new cast on the left arm. Which finding should the nurse report to the healthcare provider immediately?

• A. Client reports itching under the cast
• B. Client reports pain at the cast site
• C. Client reports swelling of the fingers
• D. Client reports warmth over the casted area

Correct answer: C

Rationale: Swelling of the fingers can indicate compromised circulation, which is a serious concern in a client with a new cast. It could suggest the development of compartment syndrome, a condition where increased pressure within the muscles can lead to impaired blood flow. This can result in tissue damage and should be addressed promptly. Itching under the cast, pain at the cast site, and warmth over the casted area are common findings after cast application and may not necessarily indicate an urgent issue requiring immediate reporting to the healthcare provider.

3. The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client’s plan of care?

• A. Monitor serum calcium levels
• B. Obtain a baseline electrocardiogram
• C. Implement seizure precautions
• D. Encourage a low-protein diet

Correct answer: C

Rationale: The correct answer is to implement seizure precautions. Phenytoin is an antiepileptic medication used for seizure control. Seizure precautions are crucial for clients taking this medication to ensure their safety during a seizure episode. Monitoring serum calcium levels (Choice A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (Choice B) is important for some medications but not the priority for a client on phenytoin. Encouraging a low-protein diet (Choice D) is not specifically indicated for clients on phenytoin and is not the most important intervention.

4. A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?

• A. I should keep the urine specimen refrigerated.
• B. I need to start the collection in the morning after my first void.
• C. I will collect the urine for 24 hours and keep it on ice.
• D. I will start collecting the urine after discarding my first morning specimen.

Correct answer: D

Rationale: The correct way to collect a 24-hour urine specimen is to discard the first morning void and then start the collection. Choice A is incorrect because refrigeration is not typically necessary for a 24-hour urine specimen. Choice B is incorrect as the client needs to discard the first void. Choice C is incorrect; while collecting urine for 24 hours is correct, keeping it on ice is not standard procedure.

5. The nurse enters the room of a client with a nasogastric tube who is receiving continuous feeding. The nurse observes that the client is coughing and that the infusion pump is alarming. What action should the nurse take first?

• A. Auscultate the client's breath sounds
• B. Turn the client to the side
• C. Stop the feeding infusion
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct action for the nurse to take first in this situation is to stop the feeding infusion. Coughing in a client with a nasogastric tube can indicate aspiration, which can be a serious complication. By stopping the feeding infusion immediately, the nurse can prevent further aspiration and related complications. Auscultating breath sounds or turning the client to the side may be necessary actions but addressing the feeding infusion is the priority. Notifying the healthcare provider can be done after the immediate issue of potential aspiration is managed.

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