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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 nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which of the following information should the nurse include?
- A. Frequent hand washing prevents infection
- B. Prolonged use of corticosteroids increases infection risk
- C. Limit patient interaction to reduce infection spread
- D. Restrict client movement to prevent contamination
Correct answer: B
Rationale: The correct answer is B because prolonged use of corticosteroids is a known risk factor for infections. Choice A is incorrect because frequent hand washing actually helps prevent infections. Choice C is incorrect as patient interaction is essential in healthcare but should be done following proper infection control measures. Choice D is also incorrect as restricting client movement is not a standard practice to prevent contamination.
3. How should a healthcare professional assess a patient with fluid overload?
- A. Monitor weight and assess for edema
- B. Monitor blood pressure and auscultate lung sounds
- C. Assess for jugular venous distention
- D. Monitor oxygen saturation and check for fluid retention
Correct answer: A
Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.
4. A client with moderate anxiety disorder is being taught stress management techniques by a nurse. Which response by the client indicates an understanding of the teaching?
- A. I will take a walk to reduce my anxiety
- B. I will imagine myself in a calm place when I can't concentrate
- C. I will meditate every other week
- D. I will cut back on my caffeine intake
Correct answer: B
Rationale: The correct answer is B because imagining oneself in a calm place is a relaxation technique that helps reduce anxiety. Walking, meditating every other week, or cutting back on caffeine intake may have their benefits, but they are not as directly related to the immediate management of anxiety as the visualization technique described in option B.
5. What is the role of a nurse in managing a patient with kidney disease?
- A. Monitor blood pressure and provide dietary education
- B. Monitor urine output and provide IV fluids
- C. Administer diuretics and restrict fluid intake
- D. Monitor for cardiac arrhythmias and provide dialysis
Correct answer: A
Rationale: The correct answer is A. Nurses play a crucial role in managing patients with kidney disease by monitoring blood pressure and providing essential dietary education. This helps in maintaining kidney function and overall health. Choice B is incorrect because monitoring urine output and providing IV fluids are tasks usually performed by healthcare providers such as physicians or specialized staff. Choice C is incorrect as administering diuretics and restricting fluid intake are typically prescribed by a physician, and nurses may assist in monitoring the effects. Choice D is incorrect as monitoring for cardiac arrhythmias and providing dialysis are tasks that are usually overseen by healthcare providers with specialized training in cardiology and nephrology.
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