Nursing Elites

1. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

• A. Serum sodium 138 mEq/L
• B. Urine specific gravity 1.001
• C. Serum calcium 10 mg/dL
• D. Urine pH 6

Correct answer: B

Rationale: The correct answer is B. A urine specific gravity of 1.001 is low and indicates dilute urine, which is a sign of fluid overload (hypervolemia). Choice A, serum sodium 138 mEq/L, is within the normal range and does not indicate hypervolemia. Choice C, serum calcium 10 mg/dL, is not typically used to diagnose hypervolemia. Choice D, urine pH 6, is also not a specific indicator of hypervolemia.

2. A healthcare provider is reviewing the health history of an older adult who has a hip fracture. The healthcare provider should identify what as a risk factor for developing pressure injuries?

• A. Advanced age
• B. Urinary incontinence
• C. Regular skin assessments
• D. Adequate hydration

Correct answer: B

Rationale: Urinary incontinence is a significant risk factor for skin breakdown and pressure injuries. It can lead to prolonged skin exposure to moisture and irritants, increasing the susceptibility to pressure injuries. Advanced age (Choice A) is a risk factor due to changes in skin integrity and decreased tissue viability, but it is not as direct a risk factor as urinary incontinence. Regular skin assessments (Choice C) are important for early detection and prevention but are not a risk factor themselves. Adequate hydration (Choice D) is essential for overall skin health but is not a direct risk factor for pressure injuries.

3. A client with a history of renal failure is being cared for by a nurse. Which of the following should the nurse monitor?

• A. Fluid intake
• B. Electrolyte levels
• C. Blood pressure
• D. Both B and C

Correct answer: D

Rationale: Clients with renal failure are at risk for electrolyte imbalances and hypertension. Monitoring electrolyte levels is crucial because renal failure can lead to imbalances in sodium, potassium, and other electrolytes. Blood pressure monitoring is essential as hypertension is a common complication of renal failure. Therefore, both electrolyte levels and blood pressure should be closely monitored to detect and manage any abnormalities. Fluid intake, while important, is not specific to renal failure monitoring and is not the priority in this case.

4. A client with a closed head injury has their eyes open when pressure is applied to the nail beds, and they exhibit adduction of the arms with flexion of the elbows and wrists. The client also moans with stimulation. What is the client's Glasgow Coma Score?

• A. 4
• B. 7 (comatose)
• C. 9
• D. 10

Correct answer: B

Rationale: The client's Glasgow Coma Score is 7. This is calculated by assigning 2 points for eye-opening to pain, 2 points for incomprehensible sounds, and 3 points for flexion posturing. Choices A, C, and D are incorrect. Choice A (4) would be the score if the client displayed decerebrate posturing instead of flexion posturing. Choice C (9) would be the score if the client exhibited eye-opening to speech, confused speech, and decorticate posturing. Choice D (10) would be the score if the client showed eye-opening spontaneously, oriented speech, and obeyed commands, which is not the case here.

5. A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching?

• A. I will limit my intake of red meat to twice monthly.
• B. I can have dairy in moderate portions daily.
• C. I can have fish two times a week.
• D. I can drink wine in moderation.

Correct answer: A

Rationale: The correct answer is A. In the Mediterranean diet, red meat should be limited to two times monthly, not weekly. Choice B is correct as dairy in moderate portions daily is suitable for the Mediterranean diet. Choice C is also correct as having fish two times a week aligns with the Mediterranean diet. Choice D is correct as moderate wine consumption is a component of the Mediterranean diet.

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