Nursing Elites

1. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?

• A. Client will be able to turn self by day 3
• B. Skin will remain intact and without redness during hospital stay
• C. Client will state pain relieved within 30 minutes after medication
• D. Pressure will be prevented by repositioning client every 2 hours

Correct answer: B

Rationale: The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.

2. When are manual hematocrits done?

• A. to monitor anemia
• B. by using a microhematocrit tube.
• C. to measure the percentage of plasma to cells.
• D. All of the above.

Correct answer: D

Rationale: Manual hematocrits are performed to monitor anemia, which involves measuring the percentage of red blood cells in the blood. The process involves collecting blood in a microhematocrit tube, then centrifuging it to separate the plasma from the cells. By measuring the ratio of plasma to cells, healthcare providers can assess the patient's hematocrit level. Therefore, all the provided options are correct as they collectively describe the purpose and procedure of manual hematocrits.

3. Which of the following is an organizational factor that affects workplace violence directed at nurses?

• A. Clients who have short hospital stays
• B. The presence of security guards
• C. Restricted client areas
• D. Understaffing of nursing personnel

Correct answer: D

Rationale: Understaffing of nursing personnel is a critical organizational factor that can contribute to workplace violence directed at nurses. When there are too few nurses on duty due to understaffing, it can lead to delays in care delivery and inadequate attention to clients' needs. This situation can result in heightened frustration, aggression, or violence from clients or their families towards the nursing staff. On the other hand, the presence of security guards (Choice B) may enhance safety in the workplace and deter violence, making it an incorrect choice. Clients who have short hospital stays (Choice A) and restricted client areas (Choice C) are not directly linked to organizational factors that promote workplace violence against nurses, making them incorrect choices.

4. A patient has been told to monitor her LH levels. Which of the following potential conditions might the patient be suffering from?

• A. Menorrhagia
• B. Grave's Disease
• C. Menopause
• D. Infertility

Correct answer: D

Rationale: Luteinizing hormone (LH) is released by the pituitary gland to stimulate ovulation. One of the common reasons for monitoring LH levels is infertility. In women with infertility, LH levels are monitored to time intercourse accurately to maximize the chances of conception. Menorrhagia (choice A) is characterized by heavy menstrual bleeding and is not directly related to LH levels. Grave's Disease (choice B) is an autoimmune disorder affecting the thyroid gland and is not typically monitored by LH levels. Menopause (choice C) is a natural process marking the end of a woman's reproductive years and is not a condition where LH monitoring for infertility is common.

5. The nurse is unable to palpate the right radial pulse on a patient. What would the nurse do next?

• A. Auscultate over the area with a fetoscope.
• B. Use a goniometer to measure the pulsations.
• C. Use a Doppler device to check for pulsations over the area.
• D. Check for the presence of pulsations with a stethoscope.

Correct answer: C

Rationale: When a nurse is unable to palpate a radial pulse, the next step is to use a Doppler device to check for pulsations over the area. Doppler devices are specifically designed to augment pulse or blood pressure measurements. Auscultating with a fetoscope is used to listen to fetal heart tones and is not relevant in this scenario. Goniometers are used to measure joint range of motion and are not used to assess pulses. Stethoscopes are primarily used to auscultate breath, bowel, and heart sounds, not to check for pulsations in peripheral pulses. Therefore, the correct course of action when unable to palpate a pulse is to utilize a Doppler device to assess for pulsations in the radial pulse area.

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