Nursing Elites

1. A client who is bedridden after a stroke is at risk for developing pressure ulcers. Which nursing intervention is most important in preventing this complication?

• A. Apply lotion to the skin every 4 hours.
• B. Reposition the client every 2 hours.
• C. Elevate the head of the bed 30 degrees.
• D. Massage the skin at least twice a day.

Correct answer: B

Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers in bedridden clients. This intervention helps in relieving pressure on specific areas of the body, promoting circulation, and reducing the risk of tissue damage. Applying lotion every 4 hours (Choice A) may not address the root cause of pressure ulcers. Elevating the head of the bed (Choice C) is beneficial for some conditions but not specifically targeted at preventing pressure ulcers. Massaging the skin at least twice a day (Choice D) can actually increase the risk of skin breakdown in individuals at risk for pressure ulcers by causing friction and shearing forces on the skin.

2. The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?

• A. Increased TSH
• B. Increased thyroxine (T4)
• C. Decreased TSH
• D. Decreased T3

Correct answer: A

Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.

3. A client undergoing chemotherapy reports extreme fatigue. What should the nurse recommend to manage this symptom?

• A. Increase the dose of chemotherapy.
• B. Rest when needed and maintain a balanced diet.
• C. Perform light physical activity to reduce fatigue.
• D. Consider delaying the chemotherapy treatment.

Correct answer: B

Rationale: The correct recommendation for managing chemotherapy-induced fatigue is to advise the client to rest when needed and maintain a balanced diet. Increasing the dose of chemotherapy (Choice A) would exacerbate the fatigue and other side effects. While light physical activity (Choice C) can be beneficial, extreme fatigue may require more rest initially. Delaying chemotherapy treatment (Choice D) should only be considered after consultation with the healthcare provider, as timely treatment is usually crucial in cancer care.

4. The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding?

• A. Elevate the legs on pillows
• B. Encourage ambulation and leg exercises
• C. Provide a heating pad for warmth
• D. Offer cold packs when the pain occurs

Correct answer: C

Rationale: Providing warmth can help dilate peripheral vessels and increase blood flow, relieving ischemic pain. In PAD, where there is already compromised blood flow, elevating the legs or applying cold therapy could worsen ischemic pain by further reducing blood flow to the extremities. Encouraging ambulation and leg exercises may be beneficial in other conditions but not suitable for clients with severe PAD experiencing rest ischemia.

5. A client with pheochromocytoma is admitted to the hospital. Which intervention has the highest priority?

• A. Monitor blood pressure frequently
• B. Start intravenous fluids at a fast rate
• C. Administer pain medication to reduce discomfort
• D. Give antihypertensive medications as prescribed

Correct answer: B

Rationale: The correct answer is B: Start intravenous fluids at a fast rate. In a client with pheochromocytoma, the highest priority intervention is to ensure adequate intravascular volume before initiating any other treatment. This helps prevent a sudden drop in blood pressure that can occur due to the release of catecholamines during tumor manipulation. While monitoring blood pressure frequently is essential, ensuring adequate intravascular volume takes precedence. Administering pain medication and antihypertensive medications are important but are not the highest priority in the initial management of pheochromocytoma.

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