Nursing Elites

1. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

• A. Capillary refill of 1 second
• B. Capillary refill of 5 seconds
• C. Pitting edema
• D. Shortness of breath

Correct answer: B

Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.

2. The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors?

• A. Sleep disturbances
• B. Concomitant depression
• C. Agitation and assaultiveness
• D. Confusion and withdrawal

Correct answer: C

Rationale: The correct answer is C: Agitation and assaultiveness. Risperidone is commonly prescribed for clients with Alzheimer's disease to reduce symptoms of agitation and aggressive behavior. This medication helps in managing challenging behaviors often seen in individuals with Alzheimer's. Choice A, sleep disturbances, is incorrect as risperidone is not primarily indicated for treating sleep issues in Alzheimer's patients. Choice B, concomitant depression, is also incorrect as risperidone is not the first-line treatment for depression in Alzheimer's disease. Choice D, confusion and withdrawal, is incorrect as risperidone does not directly target these symptoms in Alzheimer's patients.

3. What are the nursing interventions for a patient with a pressure ulcer?

• A. Clean the wound and apply a hydrocolloid dressing
• B. Provide a high-protein diet and ensure bed rest
• C. Monitor for signs of infection and provide antibiotics
• D. Provide a low-sodium diet and monitor for fluid retention

Correct answer: A

Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.

4. Which of the following interventions should the nurse implement for a client with hyperkalemia?

• A. Administer calcium gluconate
• B. Increase fluid intake to promote potassium excretion
• C. Administer a diuretic
• D. Administer sodium bicarbonate

Correct answer: A

Rationale: The correct intervention for a client with hyperkalemia is to administer calcium gluconate. Calcium gluconate helps counteract the effects of hyperkalemia by stabilizing the cardiac cell membrane. Increasing fluid intake (Choice B) may not effectively lower potassium levels. Administering a diuretic (Choice C) or sodium bicarbonate (Choice D) is not the primary treatment for hyperkalemia and may not address the immediate need to lower potassium levels.

5. How should a healthcare professional manage a patient with suspected myocardial infarction (MI)?

• A. Administer oxygen and call for emergency help
• B. Monitor vital signs and provide pain relief
• C. Provide nitroglycerin and thrombolytics
• D. Administer diuretics and provide a high-protein diet

Correct answer: A

Rationale: Administering oxygen and seeking emergency help are crucial initial steps in managing a patient with suspected myocardial infarction (MI). Oxygen helps to improve oxygenation to the heart muscle, reducing its workload and preventing further damage. Calling for emergency help ensures timely access to advanced medical care, including interventions like thrombolytics. Monitoring vital signs and providing pain relief are important but secondary to the immediate need for oxygen and emergency assistance. Providing nitroglycerin and thrombolytics should be done under medical supervision and following appropriate protocols, not as the first step. Administering diuretics and altering the patient's diet are not indicated in the acute management of MI.

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