Nursing Elites

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?

• A. Serum albumin level of 3 g/dL
• B. HDL level of 90 mg/dL
• C. Norton scale score of 18
• D. Braden scale score of 20

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 collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

• A. Pressured speech
• B. Increased appetite
• C. Lack of sleep
• D. Mood swings

Correct answer: C

Rationale: The correct answer is C: 'Lack of sleep.' In a client experiencing acute mania due to bipolar disorder, lack of sleep is the priority finding for the nurse to address. Sleep deprivation can exacerbate symptoms, lead to exhaustion, and increase the risk of further complications. Pressured speech, increased appetite, and mood swings are also common in acute mania, but addressing the lack of sleep takes precedence due to its significant impact on the client's well-being and recovery.

3. A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?

• A. Bright red bleeding
• B. Burning with urination
• C. Headache
• D. Heavy lochia flow

Correct answer: B

Rationale: The correct answer is B: 'Burning with urination.' Burning with urination can indicate a urinary tract infection postpartum, which requires immediate attention to prevent complications. Bright red bleeding and heavy lochia flow are expected findings in the early postpartum period as the uterus continues to contract and expel lochia. A headache alone is not uncommon postpartum and is often attributed to hormonal changes, dehydration, or fatigue, and can be managed with adequate rest, hydration, and pain relief. Therefore, the priority here is to address the potential infection indicated by burning with urination.

4. What are the nursing interventions for a patient with neutropenia?

• A. Monitor for signs of infection and administer antibiotics
• B. Isolate the patient and provide a low-microbial diet
• C. Monitor vital signs and avoid unnecessary invasive procedures
• D. Encourage the patient to engage in social activities

Correct answer: A

Rationale: The correct nursing interventions for a patient with neutropenia include monitoring for signs of infection and administering antibiotics. Neutropenia is characterized by a low neutrophil count, which increases the risk of infections. Monitoring for signs of infection allows for early detection and prompt treatment, while administering antibiotics helps prevent or treat any infections that may occur. Isolating the patient and providing a low-microbial diet (Choice B) are not necessary unless the patient develops an active infection. Monitoring vital signs and avoiding unnecessary invasive procedures (Choice C) are important but do not specifically address the increased infection risk in neutropenic patients. Encouraging the patient to engage in social activities (Choice D) is not appropriate for a neutropenic patient due to the risk of exposure to infectious agents.

5. What is the process for taking a telephone order from a provider?

• A. Patient name, drug, dose, route, frequency
• B. Read back for accuracy
• C. Have a witness listen to the order
• D. Write down the order and follow up

Correct answer: B

Rationale: The correct process for taking a telephone order from a provider involves reading back the information for accuracy. This step ensures that the order is correctly understood and reduces the risk of errors. While listing patient information (Choice A) is essential, it does not encompass the complete process of verifying the order. Having a witness listen to the order (Choice C) may not always be practical or necessary, as direct verification is more efficient. Writing down the order and following up (Choice D) is not as crucial as the immediate read-back process, which allows for real-time clarification and confirmation.

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