Nursing Elites

1. A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?

• A. Decreased pain and increased redness around the ulcer.
• B. Increased serous drainage from the ulcer site.
• C. Cool extremities and weak peripheral pulses.
• D. Pitting edema around the ulcer site.

Correct answer: C

Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.

2. A client with cirrhosis is receiving lactulose. What is the most important assessment for the nurse to monitor?

• A. Monitor the client's ammonia levels.
• B. Monitor the client's blood glucose level.
• C. Monitor the client's potassium levels.
• D. Monitor the client's level of consciousness.

Correct answer: D

Rationale: The correct answer is to monitor the client's level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy. Monitoring the level of consciousness helps assess the effectiveness of lactulose therapy in improving the client's condition. Monitoring ammonia levels (choice A) is important, but assessing the client's response to therapy through their level of consciousness is more crucial. Blood glucose levels (choice B) and potassium levels (choice C) are not directly related to lactulose therapy for cirrhosis and hepatic encephalopathy.

3. The client provides three positive responses to the CAGE questionnaire. Which interpretation should the nurse provide?

• A. The CAGE is a tool for identifying substance abuse.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response indicates potential alcohol issues.
• D. All responses must be positive for alcohol dependence.

Correct answer: B

Rationale: The CAGE questionnaire is a widely used screening tool for alcohol dependence. Two or more positive responses suggest a higher likelihood of alcohol dependence. One positive response may indicate potential alcohol issues, but two or more significantly increase the likelihood of dependence. Therefore, choice B is the most appropriate interpretation. Choice A is incorrect because the CAGE questionnaire specifically focuses on alcohol-related issues, not substance abuse in general. Choice C is incorrect as one positive response does not indicate addiction but rather raises a concern. Choice D is incorrect as not all responses need to be positive to suggest alcohol dependence.

4. The nurse is preparing a client who had a BKA amputation for discharge to home. Which recommendations should the nurse provide this client?

• A. All of the above
• B. Inspect the skin for redness
• C. Use a residual limb shrinker
• D. Wash the stump with soap and water

Correct answer: A

Rationale: Proper care of the residual limb is essential in preventing complications like infection or poor healing. By choosing 'All of the above,' the nurse ensures that the client receives comprehensive care. Inspecting the skin for redness is crucial as it can help in early detection of infections. Using a residual limb shrinker helps reduce swelling and maintain proper shaping of the limb. Washing the stump with soap and water on a daily basis is important for hygiene and preventing infections. Therefore, all the recommendations (choices A, B, and C) are essential for the client's care, making choice A the correct answer. Choice D is incorrect as it does not encompass all the necessary recommendations for the client's care.

5. A client with chronic kidney disease is prescribed erythropoietin. What is the nurse's priority action?

• A. Monitor the client's hemoglobin and hematocrit.
• B. Monitor the client's blood pressure.
• C. Assess the client for signs of infection.
• D. Monitor the client for signs of bleeding.

Correct answer: A

Rationale: The correct answer is A: 'Monitor the client's hemoglobin and hematocrit.' When a client with chronic kidney disease is prescribed erythropoietin, the nurse's priority action is to monitor the client's hemoglobin and hematocrit. Erythropoietin stimulates red blood cell production, so monitoring these lab values helps evaluate the effectiveness of erythropoietin in treating anemia. Monitoring the client's blood pressure (choice B) is important but not the priority in this scenario. Assessing the client for signs of infection (choice C) is important but not the priority related to the prescription of erythropoietin. Monitoring the client for signs of bleeding (choice D) is relevant but not the priority action when erythropoietin is prescribed.

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