Nursing Elites

1. A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

• A. Elevate the head of the bed no more than 45 degrees
• B. Apply cornstarch to keep sensitive skin areas dry
• C. Massage the skin over the client's bony prominences
• D. Use a transfer device to lift the client up in bed

Correct answer: D

Rationale: The correct answer is to use a transfer device to lift the client up in bed. This intervention helps reduce friction and the risk of skin breakdown, aiding in the prevention of pressure ulcers. Elevating the head of the bed no more than 45 degrees can help with respiratory issues but does not directly address skin integrity. Applying cornstarch may lead to further skin irritation. Massaging over bony prominences can increase the risk of skin damage rather than maintaining skin integrity.

2. Which factor places a patient at the highest risk for infection?

• A. A healthy immune system
• B. Presence of chronic illness
• C. Being well-nourished
• D. Age over 65 years

Correct answer: B

Rationale: The presence of chronic illness is the factor that places a patient at the highest risk for infection. Chronic illness can compromise the immune system's ability to fight off infections effectively, making individuals more susceptible to getting sick. Option A, a healthy immune system, actually reduces the risk of infection. Option C, being well-nourished, can support overall health but does not directly correlate with infection risk. While age over 65 years is a risk factor for certain infections due to age-related immune system changes, chronic illness has a more significant impact on infection risk.

3. A client scheduled for a CT scan of the head with contrast is being taught by a nurse. Which of the following statements by the client indicates a need for further teaching?

• A. I will not eat or drink for 4 hours before the procedure
• B. I will keep my head still throughout the procedure
• C. I will experience a warm sensation when the dye is injected
• D. I can take my morning dose of metformin

Correct answer: D

Rationale: The correct answer is D because metformin should be held before a contrast CT scan to prevent the risk of kidney damage. Choices A, B, and C are all correct statements regarding the preparation and experience of a CT scan with contrast. It is important to fast before the procedure, keep the head still during the scan, and expect a warm sensation when the dye is injected.

4. After surgery, a patient is experiencing pain. What is the nurse's priority action?

• A. Administer pain medication as prescribed.
• B. Assess the patient's pain using a pain scale.
• C. Offer the patient non-pharmacological pain relief methods.
• D. Reassess the patient's pain level after 30 minutes.

Correct answer: B

Rationale: The correct answer is to assess the patient's pain using a pain scale. This is the priority action because it allows the nurse to obtain an objective measure of the patient's pain intensity. By accurately assessing the pain level, the nurse can determine the appropriate intervention, which may include administering pain medication as prescribed (choice A) or offering non-pharmacological pain relief methods (choice C). Reassessing the patient's pain level after 30 minutes (choice D) is important but comes after the initial assessment to evaluate the effectiveness of the interventions implemented.

5. A nurse is preparing to administer medications to four clients. The nurse should administer medications to which client first?

• A. A client who has pneumonia and a WBC count of 11,500/mm3 prescribed piperacillin
• B. A client who has renal failure and a serum potassium of 5.8 mEq/L prescribed sodium polystyrene sulfonate
• C. A client who is post-coronary artery bypass graft (CABG) prescribed atorvastatin
• D. A client who has anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa

Correct answer: B

Rationale: The correct answer is B. The client with renal failure and high potassium levels requires immediate attention because hyperkalemia can lead to life-threatening cardiac complications. Administering sodium polystyrene sulfonate helps lower the potassium levels. Choice A, the client with pneumonia and a high WBC count, although important, does not present an immediate life-threatening condition. Choice C, the post-CABG client prescribed atorvastatin, and Choice D, the client with anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa, do not require immediate intervention compared to managing hyperkalemia in a client with renal failure.

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