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 teaching with a group of older adults about oil-rich foods. The nurse should include which of the following foods as the equivalent of 4 tsp of oil?

• A. 1 tbsp of soft margarine
• B. ½ oz of nuts
• C. 2 tbsp of peanut butter
• D. 1 oz of sunflower seeds

Correct answer: C

Rationale: The correct answer is C: 2 tbsp of peanut butter. Two tablespoons of peanut butter is approximately equivalent to 4 teaspoons of oil, providing healthy fats in the diet. Choice A, 1 tbsp of soft margarine, is not equivalent to 4 tsp of oil as margarine contains additional ingredients. Choice B, ½ oz of nuts, and choice D, 1 oz of sunflower seeds, do not provide an equivalent amount of oil as requested in the question.

3. The parents of a child on phenytoin (Dilantin) have received discharge instructions from the nurse. Which of the following statements suggests that the teaching was effective?

• A. We will call the healthcare provider if the child develops acne.
• B. Our child should brush and floss carefully after every meal.
• C. We will skip the next dose if vomiting or fever occurs.
• D. When our child is seizure-free for 6 months, we can stop the medication.

Correct answer: B

Rationale: The correct answer is B. Proper oral hygiene, including brushing and flossing carefully after every meal, is essential for children on phenytoin to prevent gingival hyperplasia, a common side effect. Choice A is incorrect because acne is not a common side effect of phenytoin and does not require immediate healthcare provider notification. Choice C is incorrect because vomiting or fever should not prompt skipping a dose without consulting the healthcare provider first. Choice D is incorrect because discontinuing phenytoin should never be done abruptly or without healthcare provider guidance, even if the child is seizure-free for 6 months.

4. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is the appropriate action in this scenario. It helps assess the client's ability to swallow safely without the risk of aspiration. Adding a thickening agent to the fluids (Choice A) may be considered later if swallowing difficulties persist. Feeding the client only solid foods (Choice C) can increase the risk of aspiration in this case, and increasing the rate of intravenous fluids (Choice D) does not address the swallowing concern.

5. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?

• A. Pallor
• B. Increased temperature
• C. Dyspnea
• D. Involuntary muscle spasms

Correct answer: C

Rationale: Dyspnea indicates a potential complication such as pneumothorax or incorrect catheter placement, requiring immediate attention. Pallor may indicate anemia but is not as urgent as dyspnea in this context. Increased temperature could be a sign of infection but is not as critical as respiratory distress. Involuntary muscle spasms are not directly related to central venous catheter placement and are of lower priority compared to respiratory issues.

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