Nursing Elites

1. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse implement?

• A. Use a donut-shaped cushion for sitting
• B. Turn the client every 4 hours
• C. Elevate the head of the bed to 45 degrees
• D. Massage reddened areas to increase circulation

Correct answer: C

Rationale: Elevating the head of the bed reduces pressure on bony prominences, which helps prevent pressure ulcers.

2. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values indicates the TPN is effective?

• A. Albumin 3.5 g/dL
• B. Hemoglobin 8 g/dL
• C. WBC count 15,000/mm3
• D. Blood glucose 110 mg/dL

Correct answer: D

Rationale: The correct answer is D. A blood glucose level of 110 mg/dL indicates that the TPN is effective in maintaining normal glucose levels. Hemoglobin level (choice B) is related to anemia and not directly indicative of TPN effectiveness. Albumin level (choice A) is a marker of nutritional status over a longer term and may not reflect immediate TPN effectiveness. White blood cell count (choice C) is related to infection or inflammation and is not a direct indicator of TPN effectiveness.

3. A client has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Massage the injection site after administering the medication.
• B. Pinch the skin while administering the injection.
• C. Administer the medication at bedtime.
• D. Aspirate before injecting the medication.

Correct answer: B

Rationale: When administering enoxaparin, it is important to pinch the skin to ensure proper subcutaneous injection. Massaging the injection site after administering the medication is not recommended. Administering the medication at bedtime is not a specific requirement for enoxaparin. Aspirating before injecting the medication is not necessary for subcutaneous injections like enoxaparin.

4. A nurse is reviewing the laboratory results of a client who has heart failure. Which of the following findings should the nurse report to the provider?

• A. Potassium 4.0 mEq/L
• B. Hemoglobin 12 g/dL
• C. BUN 18 mg/dL
• D. Sodium 137 mEq/L

Correct answer: B

Rationale: The correct answer is B: Hemoglobin 12 g/dL. In a client with heart failure, a decrease in hemoglobin levels can indicate anemia, which can exacerbate heart failure symptoms. Reporting this finding to the provider is crucial for appropriate management. Choice A, Potassium 4.0 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not typically require immediate reporting. Choice C, BUN 18 mg/dL, and Choice D, Sodium 137 mEq/L, are also within normal ranges and not directly related to heart failure management. Therefore, the hemoglobin level is the most critical finding to report in this scenario.

5. What is the best method to monitor fluid balance in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Monitor blood pressure
• D. Monitor edema

Correct answer: A

Rationale: The best method to monitor fluid balance in a patient receiving diuretics is to monitor daily weight. Daily weighing is a precise way to assess changes in fluid status as it reflects variations in total body water. Monitoring intake and output (choice B) is also important but may not provide as accurate a measurement as daily weight. Monitoring blood pressure (choice C) is essential but does not directly measure fluid balance. Monitoring edema (choice D) is helpful to assess fluid status visually but may not be as sensitive as daily weight measurements in detecting subtle changes in fluid balance.

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