Nursing Elites

1. A healthcare professional is reviewing the health history of an older adult who has a hip fracture. What is a risk factor for developing pressure injuries?

• A. Dehydration
• B. Urinary incontinence
• C. Poor nutrition
• D. Poor tissue perfusion

Correct answer: B

Rationale: Urinary incontinence is a risk factor for developing pressure injuries due to prolonged skin exposure to moisture and irritants. Dehydration (choice A) can contribute to skin dryness but is not a direct risk factor for pressure injuries. Poor nutrition (choice C) can affect wound healing but is not specifically linked to pressure injuries. Poor tissue perfusion (choice D) can increase the risk of tissue damage but is not as directly associated with pressure injuries as urinary incontinence.

2. A nurse is preparing to administer a dose of escitalopram. Which of the following should the nurse assess first?

• A. Mood changes
• B. Blood pressure
• C. Heart rate
• D. Liver function

Correct answer: A

Rationale: The correct answer is to assess for mood changes. When administering escitalopram, it is crucial to evaluate mood changes first because the medication may take some time to demonstrate its full effects on the patient's mood. Assessing blood pressure, heart rate, or liver function is not the priority when administering escitalopram, as these parameters are not directly impacted acutely by this medication.

3. Four clients present to the emergency department. The nurse should plan to see which of the following clients first?

• A. A 6-year-old client with a dislocated shoulder
• B. A 26-year-old client with sickle cell disease and severe joint pain
• C. A 76-year-old client who is confused, febrile, and has foul-smelling urine
• D. A 50-year-old client who has slurred speech and reports a headache

Correct answer: D

Rationale: The correct answer is D. The client with slurred speech and a headache may be experiencing a stroke, which is a medical emergency that requires immediate attention to prevent irreversible brain damage. While each client requires prompt assessment and care, the priority is to address potentially life-threatening conditions first. Choices A, B, and C, although important, do not present with symptoms as critical as those of a possible stroke, which necessitates urgent intervention.

4. When reinforcing teaching about self-care with a patient who has pelvic inflammatory disease and does not speak English, what action by the nurse is appropriate?

• A. Provide written instructions in English.
• B. Use family members as translators.
• C. Seek assistance from a facility-approved interpreter.
• D. Use online translation tools.

Correct answer: C

Rationale: When communicating with a patient who does not speak English, it is crucial to seek assistance from a facility-approved interpreter. Using family members as translators can lead to inaccuracies, breaches in confidentiality, and discomfort for the patient. Online translation tools may not provide accurate or context-specific translations, which can result in misunderstandings. Providing written instructions in English would not be effective if the patient does not understand the language.

5. A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

• A. Massage the fundus
• B. Administer oxytocin
• C. Assist the client to void then reassess the fundus
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct intervention for a postpartum client with a firm, displaced fundus is to assist the client to void then reassess the fundus. Displacement of the uterus to the right is often a sign of bladder distention, which can prevent the uterus from contracting properly and increase the risk of postpartum hemorrhage. By helping the client to void, the nurse can alleviate the bladder distention, allowing the uterus to contract effectively. Massaging the fundus (Choice A) may not address the underlying issue of bladder distention. Administering oxytocin (Choice B) is not indicated without assessing and addressing the cause of the displacement. Notifying the healthcare provider (Choice D) is premature before implementing initial nursing interventions to address the potential cause of the displaced fundus.

Similar Questions