Nursing Elites

1. A nurse is contributing to the plan of care for a client who is at risk of developing pressure injuries. Which of the following interventions should the nurse include?

• A. Place the client in a prone position
• B. Place the client in a 30-degree lateral position
• C. Encourage the client to reposition every 4 hours
• D. Place the client in a high Fowler's position

Correct answer: B

Rationale: The correct answer is B: Place the client in a 30-degree lateral position. Positioning the client laterally reduces pressure on bony prominences, improving circulation and helping prevent pressure injuries. Placing the client in a prone position (choice A) increases pressure on the bony prominences, raising the risk of pressure injuries. Similarly, placing the client in a high Fowler's position (choice D) can also increase pressure on certain areas. While encouraging the client to reposition every 4 hours (choice C) is important, the specific lateral positioning is more beneficial in preventing pressure injuries.

2. The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?

• A. The child is placed in a private room
• B. The staff removes a toy from the child's bed and takes it to the nurse's station
• C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack
• D. The staff uses standard precautions

Correct answer: A

Rationale: The correct answer is A. Private room placement is crucial when caring for a patient with hepatitis A to prevent the transmission of the disease to others. Placing the child in a private room helps contain the infection and protect other patients and staff. Choices B, C, and D are incorrect because removing a toy from the child's bed, offering specific snacks, or using standard precautions, while important in general care, are not specific measures required to prevent the spread of hepatitis A.

3. What are the risk factors for pressure ulcer development?

• A. Immobility and poor nutrition
• B. Obesity and diabetes
• C. Dehydration and malnutrition
• D. Use of assistive devices and prolonged bedrest

Correct answer: A

Rationale: Corrected Rationale: The correct answer is immobility and poor nutrition. Immobility can lead to constant pressure on certain areas of the body, while poor nutrition can impair tissue repair and regeneration, both contributing to the development of pressure ulcers. Choices B, C, and D are incorrect because while obesity, diabetes, dehydration, malnutrition, use of assistive devices, and prolonged bedrest can impact skin integrity and wound healing, they are not the primary risk factors specifically associated with pressure ulcer development.

4. A nurse is teaching a client who is at risk for developing osteoporosis. Which of the following recommendations should the nurse make?

• A. Walk for at least 30 minutes each day
• B. Avoid sunlight exposure
• C. Take vitamin B12 supplements
• D. Increase calcium intake to 1,500 mg per day

Correct answer: D

Rationale: The correct answer is to increase calcium intake to 1,500 mg per day. Adequate calcium intake is essential for maintaining bone density and reducing the risk of osteoporosis. Walking for at least 30 minutes each day is beneficial for overall health but is not as directly related to osteoporosis prevention as calcium intake. Sunlight exposure is important for vitamin D synthesis, which is necessary for calcium absorption, so avoiding sunlight exposure would not be recommended. Vitamin B12 supplements are not directly related to bone health or osteoporosis prevention, so this would not be the most appropriate recommendation.

5. What is the priority nursing action for a client with dehydration?

• A. Administer oral fluids
• B. Monitor electrolyte levels
• C. Administer antiemetics as needed
• D. Encourage bed rest

Correct answer: B

Rationale: The priority nursing action for a client with dehydration is to monitor electrolyte levels. Dehydration can cause imbalances in electrolytes such as sodium and potassium, affecting essential bodily functions. Monitoring electrolyte levels is crucial to promptly identify and correct any imbalances. While administering oral fluids (Choice A) is vital in treating dehydration, monitoring electrolyte levels takes precedence as it directly addresses the underlying imbalance. Administering antiemetics (Choice C) may be necessary for nausea and vomiting but is not the priority over electrolyte monitoring. Encouraging bed rest (Choice D) can conserve energy but is not as critical as monitoring electrolyte levels to prevent complications related to electrolyte imbalances.

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