Nursing Elites

1. A client has a pressure ulcer. Which of the following findings indicates healing of the ulcer?

• A. Increase in drainage.
• B. Decrease in size.
• C. Presence of foul odor.
• D. Reddened wound edges.

Correct answer: B

Rationale: When a pressure ulcer is healing, there is a decrease in its size as the tissue repair progresses. This reduction in size is a positive indication of the healing process. An increase in drainage, presence of foul odor, or reddened wound edges are typically signs of infection or lack of improvement. Therefore, the correct answer is a decrease in size.

2. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?

• A. Tremors
• B. Urine retention
• C. Kussmaul respirations
• D. Bradypnea

Correct answer: C

Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.

3. A client is postoperative following abdominal surgery. Which of the following actions should be taken to prevent respiratory complications?

• A. Instruct the client to exhale into an incentive spirometer
• B. Reposition the client every 8 hours
• C. Assist the client with early ambulation
• D. Maintain the client on bed rest for the first 48 hours

Correct answer: C

Rationale: Assisting the client with early ambulation is crucial in preventing respiratory complications after abdominal surgery. Early ambulation helps to prevent conditions like atelectasis and pneumonia by promoting lung expansion and preventing pooling of respiratory secretions. It also aids in improving circulation, reducing the risk of deep vein thrombosis, and enhancing overall recovery. Instructing the client to exhale into an incentive spirometer (Choice A) is beneficial for lung expansion but is more focused on respiratory therapy rather than preventing complications. Repositioning the client every 8 hours (Choice B) is important for preventing pressure ulcers but is not directly related to preventing respiratory complications. Maintaining the client on bed rest for the first 48 hours (Choice D) can lead to complications such as atelectasis, pneumonia, and deep vein thrombosis due to decreased lung expansion and mobility.

4. A client with a new diagnosis of chronic kidney disease is being taught about dietary management. Which of the following statements should be included in the teaching?

• A. Increase your intake of protein-rich foods.
• B. Decrease your intake of phosphorus-rich foods.
• C. Avoid foods that contain lactose.
• D. Increase your intake of potassium-rich foods.

Correct answer: B

Rationale: In chronic kidney disease, decreasing the intake of phosphorus-rich foods is essential as impaired kidney function can lead to difficulty in excreting phosphorus, causing an imbalance. This can result in bone and heart complications. Therefore, educating the client to reduce phosphorus intake is crucial for managing the disease and preventing further complications. Option A is incorrect because excessive protein intake can burden the kidneys. Option C is not directly related to the management of chronic kidney disease. Option D is also incorrect as potassium intake may need to be limited in certain stages of kidney disease.

5. A client with osteoporosis is being taught about dietary management. Which statement indicates an understanding of the teaching?

• A. I should increase my intake of foods high in vitamin D.
• B. I should decrease my intake of foods high in calcium.
• C. I should increase my intake of foods high in phosphorus.
• D. I should decrease my intake of foods high in potassium.

Correct answer: A

Rationale: The correct answer is A. Increasing intake of foods high in vitamin D is beneficial for improving calcium absorption and managing osteoporosis. Vitamin D helps the body absorb calcium, which is essential for bone health and can aid in managing osteoporosis effectively. Choice B is incorrect because reducing calcium intake would be counterproductive for a client with osteoporosis, as calcium is crucial for bone strength. Choice C is incorrect as phosphorus, while important for bone health, does not directly impact osteoporosis management as much as vitamin D and calcium. Choice D is incorrect as potassium is not directly linked to osteoporosis management, and reducing its intake is not typically part of dietary recommendations for osteoporosis.

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