Nursing Elites

1. When working with a large population of African-American clients at a community health center, which priority assessment should a nurse include?

• A. Measure height and weight.
• B. Assess blood pressure.
• C. Observe for any signs of abuse.
• D. Ask about medications.

Correct answer: B

Rationale: Assessing blood pressure is the priority assessment when working with a population of African-American clients due to the high prevalence of hypertension in this group. African Americans have a higher risk of hypertension, which can lead to complications like end-stage renal disease. Monitoring blood pressure allows for the early detection and management of hypertension. While measuring height and weight, observing for signs of abuse, and asking about medications are important assessments, assessing blood pressure is crucial in this context to address the specific health needs of African-American clients.

2. A client recovering from surgery has a large abdominal wound. Which of the following foods, high in vitamin C, should the nurse encourage the client to eat to promote wound healing?

• A. Steak
• B. Veal
• C. Cheese
• D. Oranges

Correct answer: D

Rationale: Oranges are a rich source of vitamin C, which is essential for wound healing due to its role in collagen synthesis. Citrus fruits like oranges, as well as other fruits and vegetables such as strawberries, kiwi, bell peppers, and broccoli, are high in vitamin C. Meats like steak and veal are not significant sources of vitamin C; they are primarily sources of protein. Cheese is not a good source of vitamin C but does provide calcium and protein.

3. A client with bladder cancer who underwent a complete cystectomy with ileal conduit is being assessed by a nurse. Which assessment finding should prompt the nurse to urgently contact the healthcare provider?

• A. The ileostomy is draining blood-tinged urine.
• B. There is serous sanguineous drainage on the surgical dressing.
• C. The ileostomy stoma appears pale and cyanotic.
• D. Oxygen saturations are 92% on room air.

Correct answer: C

Rationale: A pale or cyanotic appearance of the ileostomy stoma indicates compromised circulation, which can lead to necrosis if not promptly addressed. On the other hand, blood-tinged urine and serous sanguineous drainage are common following a complete cystectomy with ileal conduit. These findings do not typically indicate an urgent issue. An oxygen saturation of 92% on room air is slightly below the normal range but does not warrant urgent healthcare provider contact unless accompanied by significant respiratory distress or other concerning symptoms.

4. When a patient is receiving high doses of a cephalosporin, which laboratory values will this patient's nurse monitor closely?

• A. Blood urea nitrogen (BUN), serum creatinine, and liver function tests
• B. Complete blood count and electrolytes
• C. Serum calcium and magnesium
• D. Serum glucose and lipids

Correct answer: A

Rationale: When a patient is receiving high doses of a cephalosporin, such as cefazolin, the nurse should closely monitor laboratory values that indicate renal and hepatic function. This includes checking the Blood Urea Nitrogen (BUN) and serum creatinine levels to assess kidney function. Additionally, monitoring liver function tests, such as AST, ALT, ALP, LDH, and bilirubin, is essential as cephalosporins can affect liver enzymes. Therefore, options B, C, and D are incorrect as they do not specifically address the parameters that are most pertinent when administering high doses of cephalosporins.

5. A client with a chest tube attached to a closed drainage system has undergone a chest x-ray, which revealed that the affected lung is fully reexpanded. The nurse anticipates that the next assessment of the chest tube system will reveal:

• A. No fluctuation in the water seal chamber
• B. Continuous bubbling in the water seal chamber
• C. Increased drainage in the collection chamber
• D. Continuous gentle suction in the suction control chamber

Correct answer: A

Rationale: When the client's lung is fully reexpanded, the chest tube drainage system will no longer be actively draining, and there will be no fluctuation in the water seal chamber. Option B, continuous bubbling in the water seal chamber, indicates an air leak in the system, which is not expected when the lung is fully expanded. Option C, increased drainage in the collection chamber, would not be expected when the lung is reexpanded as there should be minimal to no drainage. Option D, continuous gentle suction in the suction control chamber, would not be appropriate when the lung is fully reexpanded and the chest tube is typically on a water seal system at this point to promote reexpansion and prevent air from entering the pleural space.

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