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. The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?

• A. Incessant crying
• B. Coughing at nighttime
• C. Choking with feedings
• D. Severe projectile vomiting

Correct answer: C

Rationale: In esophageal atresia and tracheoesophageal fistula, the esophagus ends before it reaches the stomach, forming a blind pouch, and there is an abnormal connection (fistula) with the trachea. Any child who exhibits the '3 Cs'"?coughing and choking with feedings and unexplained cyanosis"?should be suspected to have tracheoesophageal fistula. Option A, 'Incessant crying,' is not a typical sign of esophageal atresia with tracheoesophageal fistula. Option B, 'Coughing at nighttime,' is not a specific sign associated with this condition. Option D, 'Severe projectile vomiting,' is not a common sign of esophageal atresia with tracheoesophageal fistula.

3. A 34-year-old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the healthcare provider before administration?

• A. Ribavirin (Rebetol, Copegus) 600 mg PO bid
• B. Pegylated α-interferon (PEG-Intron, Pegasys) SQ weekly
• C. Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching
• D. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea

Correct answer: B

Rationale: The correct answer is B: Pegylated α-interferon (PEG-Intron, Pegasys) SQ weekly. Pegylated α-interferon is typically administered once weekly, not daily. Therefore, this medication requires further discussion with the healthcare provider before administration to ensure the correct dosing frequency. Ribavirin, choice A, is appropriate for chronic hepatitis C treatment. Choices C and D, Diphenhydramine and Dimenhydrinate, are commonly used for symptomatic relief in patients with hepatitis C and do not require further discussion with the healthcare provider in this context.

4. The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

• A. Nutrition
• B. Elimination
• C. Activity
• D. Safety

Correct answer: D

Rationale: In caring for a client with severe depression, safety is a critical priority. The nurse must address precautions to prevent suicide as part of the care plan. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the immediate risk of harm associated with depression. Ensuring the client's safety by implementing measures to prevent self-harm or suicide is the priority intervention. Addressing nutrition, elimination, and activity can follow once the client's safety is assured.

5. While taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer, the nurse learns that the patient is complaining of epigastric pain. What assessment finding would the nurse expect to note?

• A. Melena
• B. Nausea
• C. Hernia
• D. Hyperthermia

Correct answer: A

Rationale: Melena is the passage of black, tarry stools due to the presence of blood in the gastrointestinal tract, usually originating from the upper digestive system. In the context of a Duodenal Ulcer, melena can occur as a result of bleeding in the duodenum or the upper part of the small intestine. This finding is significant as it indicates potential gastrointestinal bleeding, which is a common complication of duodenal ulcers. Nausea (Choice B) is a nonspecific symptom that may be present with various gastrointestinal conditions but is not specific to duodenal ulcers. Hernia (Choice C) involves the protrusion of an organ through the wall of the cavity that normally contains it and is not directly related to the symptoms of a duodenal ulcer. Hyperthermia (Choice D), which refers to an elevated body temperature, is not typically associated with duodenal ulcers unless there are severe complications present.

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