Nursing Elites

1. A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?

• A. Back Pain
• B. Fever and Chills
• C. Risk for Bleeding
• D. Dizziness

Correct answer: C

Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.

2. When analyzing the results of the urinalysis collected preoperatively from a child with epispadias scheduled for surgical repair, which finding should the nurse most likely expect to note?

• A. Hematuria
• B. Proteinuria
• C. Bacteriuria
• D. Glucosuria

Correct answer: C

Rationale: Epispadias is a congenital defect characterized by the abnormal placement of the urethral orifice of the penis, often on the dorsum. This anatomical anomaly predisposes individuals to bacterial entry into the urinary tract, leading to bacteriuria. Hematuria, proteinuria, and glucosuria are not typically associated with epispadias. Hematuria refers to the presence of blood in the urine, proteinuria indicates protein in the urine, and glucosuria is the presence of glucose in the urine, none of which are commonly seen in epispadias.

3. Why should a 30-year-old Caucasian woman who works the night shift take Vitamin D supplements?

• A. It's a standard part of the overall nutritional treatment for the prevention of osteomalacia.
• B. It helps your intestines absorb calcium, which is important for bone formation.
• C. It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone formation.
• D. Vitamin D supplements should not be taken by someone of your age.

Correct answer: B

Rationale: The correct answer is B: 'It helps your intestines absorb calcium, which is important for bone formation.' Vitamin D plays a crucial role in aiding the absorption of calcium from the intestines into the bloodstream, which is essential for bone health and formation. Choice A is incorrect because it does not specifically address the role of Vitamin D in calcium absorption. Choice C is incorrect as Vitamin D does not stimulate skin cells to produce calcium; rather, it helps regulate calcium levels in the body. Choice D is incorrect as age alone is not a contraindication for Vitamin D supplementation; the need for supplementation is based on individual health status and risk factors.

4. A client is being assessed for risks of a pressure ulcer by a healthcare professional. What is the best description of what may be found with an early pressure ulcer in an African American client?

• A. Skin has a purple/bluish color
• B. Capillary refill is 1 second
• C. Skin appears blanched at the pressure site
• D. Tenting appears when checking skin turgor

Correct answer: A

Rationale: When assessing for signs of developing pressure ulcers in a client with dark skin, traditional signs like blanching may not be evident. In individuals with darker skin tones, the skin of an early pressure ulcer may present with a purple or bluish hue. This discoloration can be a crucial indicator of compromised circulation and tissue damage. Capillary refill, blanching, and tenting are more commonly used in the assessment of skin integrity and hydration levels but may not be as reliable in individuals with darker skin tones, making the purple/bluish color a key finding in this context.

5. A patient diagnosed with epilepsy is receiving discharge education from a nurse. Which of the following teachings should be emphasized the most?

• A. Avoid consuming alcohol and drugs
• B. Adhere to follow-up appointments with the neurologist, physician, or other healthcare provider as directed
• C. Continue taking anticonvulsants, even if seizures have ceased
• D. Wear a medical alert bracelet or carry an ID card indicating epilepsy

Correct answer: C

Rationale: The most critical teaching that the nurse should stress to a patient with epilepsy is to continue taking anticonvulsants even if seizures have stopped. Suddenly stopping antiepileptic drugs can lead to seizures and an increased risk of status epilepticus, a life-threatening condition. Choice A, advising to avoid alcohol and drugs, is important but not as crucial as maintaining anticonvulsant therapy. Choice B, emphasizing follow-up appointments, is essential but ensuring medication compliance is more critical to prevent seizure recurrence. Choice D, wearing a medical alert bracelet, is important for emergency identification but does not directly impact the patient's immediate safety like medication adherence does.

Similar Questions