Nursing Elites

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 with a pressure ulcer is being cared for by a nurse. Which of the following is the most appropriate action?

• A. Use a phenol solution to clean the wound
• B. Place a warm compress over the wound
• C. Cleanse the wound from the center outwards
• D. Administer antibiotics prophylactically

Correct answer: C

Rationale: Cleaning a wound from the center outwards is the most appropriate action as it helps prevent the spread of infection. Choice A is incorrect as phenol solutions can be harmful to the wound and delay healing. Choice B may increase the risk of infection as warmth can promote bacterial growth. Choice D is unnecessary unless there are signs of infection present.

3. A client with a chest tube is post-op. What is the priority nursing action?

• A. Clamp the chest tube every 2 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the proper functioning of the chest tube. This action is crucial post-op to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube every 2 hours (Choice A) is incorrect as it can lead to a buildup of pressure within the chest, risking complications. Encouraging deep breathing and coughing every 2 hours (Choice C) is important for respiratory hygiene but not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing to clear secretions (Choice D) is not the priority when assessing a chest tube post-op; ensuring the chest tube's integrity and function take precedence.

4. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

• A. The client's urine test is positive for glucose and acetone
• B. The client has 1+ pedal edema in both feet at the end of the day
• C. The client complains of an increase in vaginal discharge
• D. The client says she feels pressure against her diaphragm when the baby moves

Correct answer: A

Rationale: The correct answer is A. Positive urine glucose and acetone could indicate gestational diabetes or preeclampsia, both of which are complications. Choice B, pedal edema, is common in pregnancy but may also be a sign of preeclampsia if severe. Choice C, an increase in vaginal discharge, is a normal finding in pregnancy due to hormonal changes. Choice D, pressure against the diaphragm when the baby moves, is a normal sensation due to the growing uterus displacing abdominal contents.

5. When caring for a client with a wound infection, what should the nurse prioritize?

• A. Change the dressing daily
• B. Cleanse the wound with an antiseptic solution
• C. Apply a wet-to-dry dressing to the wound
• D. Perform a wound culture before administering antibiotics

Correct answer: D

Rationale: The nurse should prioritize performing a wound culture before administering antibiotics to ensure appropriate treatment. This step helps identify the specific infecting organism and its susceptibility to different antibiotics, guiding effective antibiotic therapy. Changing the dressing daily (Choice A) is important but comes after assessing the infection and initiating appropriate treatment. Cleansing the wound with an antiseptic solution (Choice B) and applying a wet-to-dry dressing (Choice C) are interventions that may be necessary but are secondary to determining the most suitable antibiotic therapy based on the wound culture results.

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