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. The nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

Correct answer: C

Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence while managing fatigue. This approach encourages the client to regain autonomy by engaging in self-care activities at their own pace. Requesting an occupational therapy consult (Choice A) may be beneficial but does not directly address the client's concern regarding fatigue and self-care. Assigning assistive personnel (Choice B) may hinder the client's independence by taking over tasks the client could potentially perform. Asking about family assistance (Choice D) does not empower the client to regain self-care abilities.

3. What are the primary differences between Type 1 and Type 2 diabetes in terms of pathophysiology and treatment?

Correct answer: A

Rationale: The correct answer is A. Type 1 diabetes is characterized by the absence of insulin production, while Type 2 diabetes involves insulin resistance. Choice B is incorrect because Type 1 diabetes is not related to insulin resistance. Choice C is inaccurate as Type 1 diabetes is autoimmune while Type 2 diabetes is more associated with lifestyle factors. Choice D is not correct since insulin therapy is primarily used in Type 1 diabetes, whereas diet modification is a common approach in managing Type 2 diabetes.

4. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?

Correct answer: C

Rationale: The correct answer is C: Serum potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Therefore, the nurse should monitor the client's serum potassium levels to prevent hyperkalemia, which can be a potential side effect of spironolactone. Monitoring total bilirubin levels (A) is not specifically required for clients taking spironolactone. Urine ketones (B) are not directly influenced by spironolactone use. Platelet count (D) is not typically monitored in clients taking spironolactone.

5. A client with coronary artery disease (CAD) is taking a low-dose aspirin daily. The nurse is reinforcing teaching with the client. The nurse should include that this medication has which of the following therapeutic effects?

Correct answer: B

Rationale: The correct answer is B: Antiplatelet. Aspirin works by inhibiting platelet aggregation, making it an antiplatelet agent. This effect helps reduce the risk of blood clot formation in clients with CAD. Choice A, Analgesic, is incorrect because aspirin's primary action in this context is not pain relief. Choice C, Anticoagulant, is incorrect as aspirin does not directly inhibit coagulation factors. Choice D, Thrombolytic, is incorrect as aspirin does not actively break down clots but rather prevents their formation.

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