Nursing Elites

1. The healthcare provider should utilize data about which of the following to provide information about the nutritional status of a client being evaluated for malnutrition?

• A. triceps skinfold measurement
• B. fasting blood glucose level
• C. hemoglobin A1c level
• D. serum lipid profile results

Correct answer: A

Rationale: Objective anthropometric measurements such as triceps skinfold and mid-arm circumference (MAC), along with weight, are usually used to diagnose malnutrition. Triceps skinfold measurement specifically helps assess body fat and muscle mass, providing valuable information about the client's nutritional status. Fasting blood glucose level, hemoglobin A1c level, and serum lipid profile results are important tests in assessing different aspects of health such as diabetes management and cardiovascular risk, but they are not specific indicators of malnutrition.

2. A 3-day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse's best action?

• A. Call the surgeon immediately.
• B. Administer Extra Strength Tylenol per orders.
• C. Assess the surgical site.
• D. Offer extra blankets and increase fluids.

Correct answer: A

Rationale: The correct answer is to call the surgeon immediately. The client's symptoms of being chilled and nauseated, along with an elevated temperature (100.4�F), could indicate an infection following the knee replacement surgery. In this scenario, prompt action is crucial to prevent any potential complications. Calling the surgeon allows for further assessment, possible diagnostic tests, and appropriate interventions to be initiated. Administering Tylenol or offering blankets and fluids may temporarily alleviate symptoms but do not address the underlying issue of a potential infection. Assessing the surgical site is important but not as urgent as involving the surgeon in this situation.

3. When treating anemia in clients with renal failure, erythropoietin should be given in conjunction with:

• A. iron, folic acid, and B12.
• B. an increase in protein in the diet.
• C. vitamins A and C.
• D. an increase in calcium in the diet.

Correct answer: A

Rationale: Erythropoietin is used to stimulate red blood cell production in clients with renal failure. To effectively increase red blood cell production, adequate levels of iron, folic acid, and B12 are necessary. These nutrients play crucial roles in erythropoiesis. Choices B, an increase in protein in the diet, is not directly related to enhanced erythropoiesis and can potentially worsen uremia. Choices C and D, vitamins A and C, and an increase in calcium in the diet, are not directly involved in red blood cell production and are not essential in this context.

4. What advice should be given to a client with stress incontinence?

• A. to consider trying Kegel exercises
• B. to undergo surgery immediately
• C. to avoid all forms of treatment
• D. to ignore the issue as it is not serious

Correct answer: A

Rationale: For stress incontinence, advising the client to consider trying Kegel exercises is appropriate. Kegel exercises involve tightening and releasing the pelvic floor muscles, which can improve stress incontinence by strengthening the muscles that control urination. Choice B suggesting immediate surgery is incorrect as surgery is usually considered after conservative treatments like Kegel exercises have been tried. Choice C advising to avoid all forms of treatment is dangerous and neglectful. Choice D recommending to ignore the issue is inappropriate as it can impact the client's quality of life and may worsen over time without intervention.

5. The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?

• A. Assist the client to a sitting position at the edge of the bed
• B. Have the client march in place for 30 seconds
• C. Have the client raise his arms above his head
• D. Ask the client the last time he fell

Correct answer: A

Rationale: The correct action to perform before ambulating a client post total knee replacement is to assist the client to a sitting position at the edge of the bed. This step is crucial to prevent orthostatic hypotension and ensure the client is ready to stand and walk safely. Having the client march in place or raise his arms above his head are not necessary preparations for ambulation. While knowing about the client's fall history is important for safety reasons, it is not the priority action immediately before ambulating the client.

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