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 1 unit of packed RBCs to a client. Which of the following findings should cause the nurse to delay the transfusion?

• A. Blood pressure 140/90 mm Hg
• B. Urine output of 40 mL/hr
• C. Temperature 38.2°C (100.8°F)
• D. Hemoglobin 8 g/dL

Correct answer: C

Rationale: A temperature of 38.2°C (100.8°F) suggests the possibility of an underlying infection or fever, which should be evaluated before proceeding with the transfusion to prevent complications. Elevated temperature can indicate an immune response to incompatible blood components, increasing the risk of a transfusion reaction. The other vital signs and lab results provided are within acceptable ranges for administering packed RBCs, making choices A, B, and D less likely to cause a delay in the transfusion.

3. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hours. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?

• A. 2100
• B. 900
• C. 1300
• D. 1800

Correct answer: D

Rationale: The trough level of vancomycin should be drawn just before the next dose is administered, typically about 30 minutes before the scheduled dose. Since the morning dose is at 0700, the trough level should be drawn at 1800. This timing ensures an accurate measurement of the lowest concentration of the drug in the client's system before the next dose is given. Choice A (2100) is too close to the next dose, choice B (900) is too early, and choice C (1300) is also too far from the next dose.

4. A nurse is caring for a client who has a deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to ambulate frequently.
• B. Apply warm, moist compresses to the affected leg.
• C. Massage the affected leg.
• D. Place the client in a supine position.

Correct answer: B

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply warm, moist compresses to the affected leg. This helps alleviate pain and improve circulation in the affected area, aiding in the treatment of DVT. Encouraging the client to ambulate frequently (Choice A) is contraindicated as it can dislodge the clot and lead to complications. Massaging the affected leg (Choice C) is also contraindicated as it can dislodge the clot and potentially cause an embolism. Placing the client in a supine position (Choice D) is not specifically indicated for DVT treatment; elevation of the affected leg is preferred over placing the client completely supine.

5. A healthcare provider is reviewing the laboratory data of a client with diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management?

• A. Postprandial blood glucose
• B. Glycosylated hemoglobin (HbA1c)
• C. Glucose tolerance test
• D. Fasting blood glucose

Correct answer: B

Rationale: The correct answer is B: Glycosylated hemoglobin (HbA1c). The glycosylated hemoglobin test measures average blood glucose levels over the past 2-3 months, providing an indication of long-term glycemic control in clients with diabetes. Choice A, postprandial blood glucose, reflects blood sugar levels after a meal and does not provide a long-term view. Choice C, glucose tolerance test, evaluates the body's ability to process sugar but does not offer a continuous assessment like the HbA1c test. Choice D, fasting blood glucose, measures blood sugar levels after a period of fasting, which is more indicative of immediate glycemic status rather than long-term management.

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