Nursing Elites

1. 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.

2. A healthcare professional is assessing a client for signs of hyperglycemia. Which of the following findings should the healthcare professional look for?

• A. Increased thirst
• B. Weight gain
• C. Decreased urination
• D. Fatigue

Correct answer: A

Rationale: Increased thirst is a classic symptom of hyperglycemia due to the body trying to eliminate excess glucose through urine, leading to dehydration and increased thirst. Weight gain, decreased urination, and fatigue are not typical signs of hyperglycemia. Weight gain is more commonly associated with conditions like hypothyroidism or fluid retention. Decreased urination is not a typical symptom of hyperglycemia, as high blood sugar levels usually lead to increased urination. Fatigue can be a symptom of hyperglycemia, but it is not as specific or characteristic as increased thirst.

3. A nurse is admitting a client who is in labor and at 38 weeks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2 (HSV-2). Which of the following questions is most appropriate for the nurse to ask the client?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask the client in this scenario is whether they have any active lesions. Active lesions from HSV-2 during labor increase the risk of neonatal transmission, which would necessitate a cesarean section to prevent the infant from contracting the virus during delivery. Asking about the presence of active lesions is crucial to determine the appropriate management and precautions needed to protect the newborn. Choices A, B, and D are not as pertinent in this situation and do not directly address the potential risk of neonatal transmission of HSV-2.

4. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: The correct answer is A: Paradoxical pulse. Paradoxical pulse, which is a significant drop in systolic blood pressure during inspiration, indicates cardiac tamponade, a life-threatening complication of pericarditis. This finding requires immediate attention as it suggests potential compromised cardiac function. Choices B, C, and D are associated with pericarditis but do not indicate the same level of urgency as paradoxical pulse.

5. The nurse instructs the patient about incentive spirometry as part of preoperative teaching. Which phase of the nursing process does this illustrate?

• A. Assessment
• B. Planning
• C. Implementation
• D. Evaluation

Correct answer: C

Rationale: Instructing a patient about incentive spirometry falls under the implementation phase of the nursing process. During this phase, nursing interventions are put into action. Assessment (choice A) involves collecting data about the patient's condition, planning (choice B) involves setting goals and creating a care plan, and evaluation (choice D) involves assessing the outcomes of nursing interventions. Therefore, the correct answer is C, as it reflects the active teaching and intervention part of the process.

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