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1. A healthcare provider is caring for a client with a pressure ulcer and needs to review the client's medical history. Which of the following findings is expected?
- A. A Braden scale score of 20
- B. An albumin level of 3 g/dL
- C. A hemoglobin level of 13 g/dL
- D. A Norton scale score of 18
Correct answer: B
Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, a common factor in the development of pressure ulcers. The Braden scale assesses the risk of developing pressure ulcers but does not reflect the client's medical history. Hemoglobin level is more related to oxygen-carrying capacity rather than pressure ulcer development. The Norton scale evaluates risk for developing pressure ulcers but is not typically part of a client's medical history.
2. A client who is at 36 weeks of gestation is being taught about nonstress testing. Which of the following statements should the nurse include in the teaching?
- A. This test will determine the length of your cervix.
- B. You will have your blood pressure taken frequently during the test.
- C. You should press the handheld button when you feel your baby move.
- D. This test will take about 5 minutes to complete.
Correct answer: C
Rationale: The correct answer is C. In a nonstress test, the client is required to press a handheld button whenever fetal movement is felt, which is then recorded on the monitor. This action helps assess the baby's heart rate in response to its movements, providing valuable information about the baby's well-being. Choices A, B, and D are incorrect because the nonstress test does not involve determining the length of the cervix, monitoring blood pressure, or being completed in 5 minutes. These aspects are not part of the nonstress testing procedure and are unrelated to the purpose of the test.
3. A nurse at a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescriptions is accurately transcribed by the nurse?
- A. KCl 10 mEq PO once daily
- B. KCl 20 mEq PO once daily
- C. Potassium gluconate PO
- D. Potassium chloride 20 mEq PO every morning
Correct answer: D
Rationale: The correct answer is D because it accurately transcribes the prescription by specifying the medication (Potassium chloride), the dose (20 mEq), the route (PO for by mouth), and the frequency (every morning). Choice A is incorrect as it specifies a lower dose compared to the correct prescription. Choice B is incorrect due to an inaccurate dose. Choice C is incorrect as it lacks specificity regarding the type of potassium prescribed and the dose.
4. Which term specifically refers to positive actions taken to help others?
- A. Beneficence
- B. Justice
- C. Autonomy
- D. Non-maleficence
Correct answer: A
Rationale: The correct answer is A, 'Beneficence.' Beneficence is the ethical principle that involves taking positive actions to help others. Choice B, 'Justice,' pertains to fairness and equity in treatment, not specifically positive actions. Choice C, 'Autonomy,' relates to respecting individuals' rights to make their own decisions, not necessarily taking actions to help others. Choice D, 'Non-maleficence,' focuses on the obligation to avoid causing harm rather than actively helping others.
5. What are the signs of an acute myocardial infarction?
- A. Chest pain radiating to the arm and shortness of breath
- B. Nausea, vomiting, and high fever
- C. Headache, confusion, and low blood pressure
- D. Increased heart rate and bradycardia
Correct answer: A
Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.
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