Nursing Elites

1. While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?

• A. A 79-year-old malnourished client on bed rest
• B. An obese client who uses a wheelchair
• C. A client who had 3 incontinent diarrhea stools
• D. An 80-year-old ambulatory diabetic client

Correct answer: A

Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to poor nutrition and immobility. Malnutrition can impair tissue healing and increase susceptibility to skin breakdown, while prolonged bed rest can lead to pressure ulcers. Choice B is incorrect because obesity can cushion pressure points and reduce the risk of pressure ulcers. Choice C is incorrect as incontinence predisposes to moisture-associated skin damage rather than pressure ulcers. Choice D is incorrect as an ambulatory client is less likely to develop pressure ulcers compared to bedridden clients.

2. A nurse is reinforcing discharge teaching with a client who has acute pancreatitis and a prescription for fat-soluble vitamin supplements. Which of the following supplements should the nurse include in the teaching?

• A. Vitamin A
• B. Vitamin B1
• C. Vitamin C
• D. Vitamin B12

Correct answer: A

Rationale: The correct answer is Vitamin A. Fat-soluble vitamins essential for patients with pancreatitis include A, D, E, and K, aiding in proper nutrient absorption. Vitamin B1 (Choice B), also known as thiamine, is a water-soluble vitamin and not a fat-soluble one. Vitamin C (Choice C) is another water-soluble vitamin and not a fat-soluble one. Vitamin B12 (Choice D) is also a water-soluble vitamin and not one of the fat-soluble vitamins crucial for patients with pancreatitis.

3. A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?

• A. Notify the healthcare provider
• B. Readjust the traction
• C. Administer the ordered PRN medication
• D. Reassess the foot in fifteen minutes

Correct answer: A

Rationale: In this situation, a pale foot with the absence of a pulse indicates compromised circulation, which is a critical emergency. The nurse should immediately notify the healthcare provider to address the circulation issue promptly. Reading the question and understanding the urgency is vital. Readjusting the traction, administering PRN medication, or waiting to reassess the foot in fifteen minutes are not appropriate actions when a child is experiencing compromised circulation.

4. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is

• A. Heart rate
• B. Pedal pulses
• C. Lung sounds
• D. Pupil responses

Correct answer: D

Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.

5. A client with hypertension taking a potassium-wasting diuretic is being educated about nutrition by a nurse. Which of the following dietary instructions should the nurse include in the teaching?

• A. Increase consumption of tuna and salmon.
• B. Limit intake of dried fruits.
• C. Avoid cow's milk.
• D. Consume organs and bananas

Correct answer: D

Rationale: The correct answer is D: 'Consume organs and bananas.' When a client is taking a potassium-wasting diuretic, they are at risk of potassium loss. Consuming foods high in potassium, such as organs and bananas, can help counteract this loss. Choice A is incorrect because tuna and salmon are not particularly high in potassium. Choice B is incorrect because dried fruits are good sources of potassium. Choice C is incorrect as cow's milk is also a good source of potassium, which could be beneficial for a client taking a potassium-wasting diuretic.

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