Nursing Elites

1. What are the risk factors for developing pneumonia in older adults?

• A. Immobility and decreased lung function
• B. Poor hygiene and aspiration
• C. Use of respiratory equipment and medications
• D. Poor nutritional status and compromised immune system

Correct answer: A

Rationale: The correct answer is A: Immobility and decreased lung function. Older adults with immobility and decreased lung function are at a higher risk of developing pneumonia. Immobility can lead to decreased lung expansion and impaired clearance of secretions, predisposing to pneumonia. While poor hygiene, aspiration, use of respiratory equipment, medications, poor nutritional status, and compromised immune system can also contribute to pneumonia risk, they are not as directly associated with pneumonia in older adults as immobility and decreased lung function.

2. A nurse in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula?

• A. Normal saline
• B. Hydrogen peroxide
• C. Iodine
• D. Alcohol

Correct answer: B

Rationale: The correct answer is B: Hydrogen peroxide. Hydrogen peroxide is commonly used to clean tracheostomy cannulas to prevent infection. Normal saline (choice A) is used for wound irrigation but not for cleaning inner cannulas of tracheostomy tubes. Iodine (choice C) and alcohol (choice D) are not recommended for cleaning tracheostomy cannulas as they can be too harsh and irritating to the delicate tissues of the airway.

3. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?

• A. Serum albumin level of 3 g/dL
• B. HDL level of 90 mg/dL
• C. Norton scale score of 18
• D. Braden scale score of 20

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.

4. A client who is newly diagnosed with iron deficiency anemia needs to include foods rich in iron in their diet. Which of the following foods should the nurse recommend as having the highest amount of iron?

• A. Boiled spinach
• B. Raw carrots
• C. Boiled chicken
• D. Yogurt

Correct answer: A

Rationale: Boiled spinach is an excellent source of iron, making it a top choice for individuals with iron deficiency anemia. Spinach contains non-heme iron, which may not be absorbed as efficiently as heme iron from animal sources but is still beneficial. Raw carrots, boiled chicken, and yogurt are not as rich in iron compared to spinach. Carrots are more known for their beta-carotene content, chicken is a good source of protein but not high in iron, and yogurt does not contain significant amounts of iron.

5. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
• B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
• C. A client who has epidural analgesia and weakness in the lower extremities.
• D. A client who has a hip fracture and a new onset of tachypnea.

Correct answer: D

Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.

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