Nursing Elites

1. A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?

• A. Massaging the reddened areas
• B. Performing range of motion exercises
• C. Administering antithrombotics as ordered
• D. Feeding the client a high-carbohydrate diet

Correct answer: B

Rationale: For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.

2. Mobility is an important human function. The hazards of immobility lead to many physical and emotional problems. Immobility can lead to detrimental cardiac, muscular, respiratory, skeletal, urinary, gastrointestinal, skin, and emotional changes. Which of the following is an example of a skeletal hazard of immobility?

• A. Contractures.
• B. Constipation.
• C. Calcium loss.
• D. Catabolism.

Correct answer: C

Rationale: All choices are hazards of immobility, but only calcium loss from the bones is a skeletal system impairment that results from immobility. Contractures are muscle shortening due to prolonged positioning, which affects the muscular system. Constipation is a gastrointestinal issue. Catabolism is a metabolic process, not specific to the skeletal system.

3. You are taking care of Mary Eden, an elderly and frail 91-year-old resident. She gets confused during evening hours and at times she thinks that she hears her daughter calling her from the other side of the nursing home. Which physical problem places Mary Eden at risk for falls?

• A. Her confusion
• B. Her daughter
• C. Evening hours
• D. Her frailness

Correct answer: D

Rationale: Mary Eden's frail and weak muscles due to her age and physical condition place her at risk for falls. While her confusion can contribute to falls, it is considered an emotional or cognitive issue rather than a physical problem. Her daughter and the evening hours are not physical problems that directly increase her risk of falling.

4. Which of the following nursing interventions is appropriate for a client suffering from a fever?

• A. Avoid withholding food from the client
• B. Increase the client's fluid intake
• C. Provide oxygen
• D. All answers are correct

Correct answer: B

Rationale: The appropriate nursing intervention for a client suffering from a fever is to increase the client's fluid intake. A fever can elevate the body's metabolism, leading to increased breathing and heart workload. This can result in fluid loss due to heightened respiration and sweating. Moreover, the augmented heart workload may necessitate more oxygen to maintain tissue perfusion. Providing oxygen and increasing fluid intake help meet the body's heightened demands during a fever. Withholding food from the client is inappropriate as proper nutrition is crucial for recovery, and providing oxygen alone may not address the fluid and metabolic demands associated with fever. Therefore, the correct choice is to increase the client's fluid intake.

5. The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?

• A. A 26-year-old woman who had a bowel resection
• B. A 40-year-old man who underwent a hernia repair
• C. A 31-year-old woman with septicemia and who is on a ventilator
• D. A 91-year-old man with Alzheimer's disease recovering from a fall

Correct answer: A

Rationale: When deciding on transferring patients between units in a hospital, it is essential to consider the appropriateness of the patient for the receiving unit. The Women's Health Center typically caters to female patients with gynecological or obstetric conditions that do not require intensive monitoring or specialized care. In this scenario, the most suitable patient for transfer to the Women's Health Center would be the 26-year-old woman who had a bowel resection, as her condition aligns more closely with the services provided in that unit. The other options, including a male patient, a critically ill patient on a ventilator, and an elderly patient with Alzheimer's disease, would not be appropriate for transfer to a Women's Health Center due to the specialized care they require, which may not align with the unit's focus and staffing capabilities.

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