a nurse is reviewing the medical records of a client who has a pressure ulcer which of the following is an expected finding
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1. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?

Correct answer: A

Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, which is commonly associated with pressure ulcers. This finding suggests that the client may be at risk for developing or already has a pressure ulcer due to malnutrition. High-density lipoprotein (HDL) level of 90 mg/dL (Choice B) is not directly related to pressure ulcers. The Norton scale (Choice C) is used to assess a client's risk of developing pressure ulcers, not as a finding in a client with an existing pressure ulcer. The Braden scale (Choice D) is also a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer.

2. A nurse is caring for a client who requests information about advance directives. Which of the following responses should the nurse make?

Correct answer: C

Rationale: The correct response is C: 'It includes end-of-life care instructions.' An advance directive is a legal document that outlines a client's preferences for medical treatment and end-of-life care in case they are unable to communicate. Choice A is incorrect because an advance directive focuses on healthcare decisions, not funeral arrangements. Choice B is incorrect as organ donation is a separate process from advance directives. Choice D is incorrect as advance directives do not provide legal guardianship rights, but rather specify healthcare wishes.

3. A client with a sprained right ankle is learning to walk with a cane. What action demonstrates effective teaching?

Correct answer: B

Rationale: When a client has a sprained right ankle, they should hold the cane in the opposite hand (left hand) to the affected leg for better support and balance. This positioning helps to reduce the weight on the injured leg while providing stability. Option A is incorrect because advancing the cane too far in front can lead to loss of balance. Option C is incorrect as it does not provide the necessary support for the injured leg. Option D is incorrect as the elbow should be slightly flexed but not necessarily at a specific angle.

4. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

Correct answer: D

Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.

5. A nurse on an acute unit has received a change of shift report for 4 clients. Which of the following clients should the nurse assess first?

Correct answer: B

Rationale: The correct answer is B because pallor in an extremity after a fracture could indicate compromised circulation, making it a priority for assessment. Choice A is not the priority as hypoactive bowel sounds in a client 1 hr postoperative, while concerning, do not indicate a life-threatening condition. Choice C, a client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses, indicates good perfusion and does not require immediate attention. Choice D, a client with an elevated AST level following the administration of azithromycin, may require further assessment but is not as urgent as the client with potential compromised circulation in choice B.

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