Nursing Elites

1. The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

• A. The nail beds.
• B. The skin in the sacral area.
• C. The skin in the abdominal area.
• D. The membranes in the ear canal.

Correct answer: A

Rationale: Jaundice, if present, can be best assessed in areas such as the sclera, nail beds, and mucous membranes due to the yellowing of these tissues. The nail beds specifically provide a good indication of jaundice. The skin in the sacral area (Option B) is not typically the best area for assessing jaundice as it is less visible and not as reliable as the nail beds. The skin in the abdominal area (Option C) may show generalized jaundice, but the nail beds are more specific for detecting early signs. Lastly, assessing the membranes in the ear canal (Option D) is not a standard method for evaluating jaundice; the sclera and nail beds are more commonly used for this purpose.

2. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

• A. Weak, nonproductive cough effort
• B. Large amounts of greenish sputum
• C. Respiratory rate of 28 breaths/minute
• D. Resting pulse oximetry (SpO2) of 85%

Correct answer: A

Rationale: The correct answer is 'Weak, nonproductive cough effort.' A weak, nonproductive cough indicates that the patient is unable to clear the airway effectively, supporting the nursing diagnosis of ineffective airway clearance. In pneumonia, secretions can obstruct the airway, leading to ineffective clearance. Choices B, C, and D do not directly reflect ineffective airway clearance. Large amounts of greenish sputum (Choice B) may suggest infection or inflammation but do not specifically indicate ineffective airway clearance. The respiratory rate of 28 breaths/minute (Choice C) and a resting pulse oximetry (SpO2) of 85% (Choice D) are more indicative of impaired gas exchange or respiratory distress rather than ineffective airway clearance.

3. A man has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea. The nurse is concerned about which side effect of lisinopril?

• A. Vertigo
• B. Hypotension
• C. Palpitations
• D. Nagging, dry cough

Correct answer: B

Rationale: The correct answer is 'Hypotension.' Lisinopril, an ACE inhibitor commonly used for CHF, can cause hypotension as a side effect. Persistent diarrhea can lead to dehydration, increasing the risk of hypotension in this patient. Vertigo (choice A) is not a typical side effect of lisinopril. Palpitations (choice C) are not directly associated with lisinopril use. A nagging, dry cough (choice D) is a common side effect of ACE inhibitors like lisinopril, but in this case, the patient's presentation with persistent diarrhea would make hypotension a more immediate concern.

4. A client is being assessed for risks of a pressure ulcer by a healthcare professional. What is the best description of what may be found with an early pressure ulcer in an African American client?

• A. Skin has a purple/bluish color
• B. Capillary refill is 1 second
• C. Skin appears blanched at the pressure site
• D. Tenting appears when checking skin turgor

Correct answer: A

Rationale: When assessing for signs of developing pressure ulcers in a client with dark skin, traditional signs like blanching may not be evident. In individuals with darker skin tones, the skin of an early pressure ulcer may present with a purple or bluish hue. This discoloration can be a crucial indicator of compromised circulation and tissue damage. Capillary refill, blanching, and tenting are more commonly used in the assessment of skin integrity and hydration levels but may not be as reliable in individuals with darker skin tones, making the purple/bluish color a key finding in this context.

5. A patient's chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?

• A. Decreased HR
• B. Paresthesias
• C. Muscle weakness of the extremities
• D. Migraines

Correct answer: D

Rationale: The correct answer is 'Migraines.' Migraines are not a symptom typically associated with hyperkalemia. In acute hyperkalemia, one would not expect to see migraines. Symptoms of hyperkalemia often include muscle weakness, paresthesias, and cardiac manifestations such as bradycardia or even cardiac arrest. Therefore, choices A, B, and C are more commonly associated with acute hyperkalemia compared to migraines, making it the correct choice.

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