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 nurse is preparing to teach a client with chronic renal failure. Which dietary instruction is most appropriate?

• A. Increase calcium intake
• B. Increase potassium intake
• C. Increase protein intake
• D. Restrict protein intake

Correct answer: D

Rationale: The correct answer is to restrict protein intake for a client with chronic renal failure. In renal failure, the kidneys are unable to effectively filter waste products. Excessive protein intake can lead to the accumulation of waste products, increasing the workload on the kidneys. Therefore, restricting protein intake is essential to prevent further kidney damage. Choices A, B, and C are incorrect. Increasing calcium intake is not specifically indicated for chronic renal failure. Increasing potassium intake can be dangerous in renal failure as impaired kidneys may not be able to excrete excess potassium. Increasing protein intake is contraindicated in chronic renal failure as it can worsen kidney function and increase the accumulation of waste products.

3. A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?

• A. A peanut butter sandwich on wheat bread
• B. A sliced apple and red grapes
• C. A chocolate chip cookie with a glass of skim milk
• D. A scrambled egg with cheddar cheese

Correct answer: B

Rationale: The correct answer is B. Clients with phenylketonuria (PKU) must adhere to a strict low-phenylalanine diet to prevent neurological damage. Foods high in phenylalanine such as peanut butter, wheat bread, chocolate chip cookies, milk, scrambled eggs, and cheddar cheese should be avoided. Sliced apples and red grapes are low in phenylalanine, making them safe choices for individuals with PKU. Choice A (peanut butter sandwich on wheat bread), Choice C (chocolate chip cookie with a glass of skim milk), and Choice D (scrambled egg with cheddar cheese) are all high in phenylalanine and should be avoided by individuals with PKU.

4. A healthcare professional is assessing a client for signs of stroke. Which of the following should the healthcare professional look for?

• A. Slurred speech
• B. Increased appetite
• C. Elevated heart rate
• D. Hyperactivity

Correct answer: A

Rationale: Corrected Question: A healthcare professional is assessing a client for signs of stroke. Slurred speech is a common sign of stroke and should be assessed immediately. Choices B, C, and D are incorrect because increased appetite, elevated heart rate, and hyperactivity are not typical signs of a stroke.

5. A nurse is caring for a client with a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

• A. Tidaling with spontaneous respirations
• B. Drainage collection chamber is 1/3 full
• C. 1 cm of water present in the water seal chamber
• D. Suction chamber pressure of -20 cm H2O

Correct answer: C

Rationale: 1 cm of water in the water seal chamber is insufficient to ensure proper functioning of the chest tube. The water seal chamber typically requires a water level of 2 cm. Tidaling with spontaneous respirations (choice A) is an expected finding indicating proper functioning. Having the drainage collection chamber 1/3 full (choice B) is within the normal range. A suction chamber pressure of -20 cm H2O (choice D) is an appropriate level for chest tube drainage.

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