Nursing Elites

1. 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.

2. Which of the following medications taken by the patient is least likely to cause urine discoloration?

• A. Sulfasalazine
• B. Levodopa
• C. Phenolphthalein
• D. Aspirin

Correct answer: D

Rationale: The correct answer is Aspirin. Aspirin is not known to cause urine discoloration. Sulfasalazine is associated with causing orange-yellow discoloration of urine. Levodopa can cause darkening of urine to a brown or black color. Phenolphthalein has been linked to pink or red discoloration of urine. Therefore, among the options provided, Aspirin is the medication least likely to cause urine discoloration.

3. The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?

• A. Neurotoxicity
• B. Hepatomegaly
• C. Nephrotoxicity
• D. Ototoxicity

Correct answer: C

Rationale: The correct answer is nephrotoxicity. Calcium disodium edetate, used in chelation therapy for lead poisoning, can lead to kidney toxicity. This is an important side effect to monitor in patients undergoing this treatment. Choices A, B, and D are incorrect. Neurotoxicity, hepatomegaly, and ototoxicity are not typically associated with calcium disodium edetate therapy for lead poisoning.

4. The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is a priority in the plan of care?

• A. Wound care
• B. Pain control measures
• C. Measurement of intake
• D. Cold and heat applications

Correct answer: A

Rationale: Following orchiopexy, the priority in the plan of care for the child's mother is wound care. The most common complications associated with orchiopexy are bleeding and infection. Discharge instructions should focus on demonstrating wound cleansing and dressing, and teaching parents to recognize signs of infection like redness, warmth, swelling, or discharge. It is crucial to prevent movement of the testicles and avoid contamination of the suture line. While analgesics may be prescribed, pain control measures are not the priority among the options presented. Measurement of intake is not essential as the child is likely to resume normal eating habits. Cold and heat applications are not typical prescribed treatments for post-orchiopexy care.

5. The healthcare provider calculates the IV flow rate for a patient receiving lactated Ringer's solution. The patient needs to receive 2000mL of Lactated Ringer's over 36 hours. The IV infusion set has a drop factor of 15 drops per milliliter. How many drops per minute should the healthcare provider set the IV to deliver?

• A. 8
• B. 10
• C. 14
• D. 18

Correct answer: C

Rationale: To determine the drops per minute, we use the formula Drops Per Minute = (Milliliters x Drop Factor) / Time in Minutes. In this case, Drops Per Minute = (2000mL x 15 drops/mL) / (36 hours x 60 minutes/hour) = 30000 / 2160 = 13.89 (approximately 14). Therefore, the correct answer is 14 drops per minute. Choice A (8), Choice B (10), and Choice D (18) are incorrect as they do not correctly calculate the drops per minute based on the given information.

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