Nursing Elites

1. A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer.

• A. Intact skin with nonblanchable redness (Stage 1)
• B. Full-thickness tissue loss with subQ damage (Stage 3)
• C. Partial-thickness skin loss involving the epidermis and dermis
• D. Full-thickness tissue loss with damage to muscle or bone (Stage 4)

Correct answer: C

Rationale: The correct answer is C. Stage 2 ulcers involve partial-thickness skin loss with visible and superficial damage, which may appear as an abrasion, blister, or shallow crater. Choice A describes a Stage 1 pressure ulcer characterized by intact skin with nonblanchable redness. Choice B describes a Stage 3 pressure ulcer with full-thickness tissue loss and damage to the subcutaneous tissue. Choice D is indicative of a Stage 4 pressure ulcer, involving full-thickness tissue loss with damage extending to muscle or bone.

2. A nurse is caring for a client with a new prescription for atorvastatin. Which of the following should the nurse monitor?

• A. Liver function tests
• B. Potassium levels
• C. Blood glucose levels
• D. Serum calcium levels

Correct answer: A

Rationale: The correct answer is A: Liver function tests. Atorvastatin, a medication commonly used to lower cholesterol levels, can potentially cause liver damage as a side effect. Monitoring liver function tests is essential to detect any abnormalities early. Choices B, C, and D are incorrect because atorvastatin is not known to directly impact potassium levels, blood glucose levels, or serum calcium levels. While these parameters may be monitored for other reasons, the priority when administering atorvastatin is to monitor liver function due to the risk of hepatotoxicity.

3. A healthcare provider is assessing a client who has a long arm cast. Which of the following findings indicates a moderate complication when assessing for acute compartment syndrome?

• A. Shortness of breath
• B. Petechiae
• C. Change in mental status
• D. Edema

Correct answer: D

Rationale: Edema is a common sign of acute compartment syndrome, which is a medical emergency caused by increased pressure within a muscle compartment, requiring immediate intervention. Shortness of breath (Choice A) is more indicative of a respiratory issue rather than acute compartment syndrome. Petechiae (Choice B) are pinpoint, round spots that appear on the skin due to bleeding under the skin and are not typically associated with acute compartment syndrome. Change in mental status (Choice C) is more suggestive of neurological issues rather than acute compartment syndrome.

4. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?

• A. Administer oxytocin to the client via intravenous infusion
• B. Apply oxygen at 2 L/min via nasal cannula
• C. Prepare for insertion of an intrauterine pressure catheter
• D. Assist the client into the knee-chest position

Correct answer: D

Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation. Administering oxytocin (Choice A) could worsen the situation by increasing contractions and potentially compressing the umbilical cord. Applying oxygen (Choice B) is not the priority in this emergency situation. Preparing for insertion of an intrauterine pressure catheter (Choice C) is not appropriate as the immediate concern is relieving pressure on the umbilical cord.

5. A client is prescribed spironolactone. Which of the following dietary instructions should the nurse include?

• A. Increase potassium-rich foods
• B. Limit sodium intake
• C. Avoid potassium supplements
• D. Increase protein intake

Correct answer: C

Rationale: The correct answer is to advise the client to avoid potassium supplements. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Adding potassium supplements on top of this medication can lead to hyperkalemia, an elevated level of potassium in the blood, which can be dangerous. Choices A, B, and D are incorrect because increasing potassium-rich foods, limiting sodium intake, and increasing protein intake are not specifically related to the dietary considerations when taking spironolactone.

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