Nursing Elites

1. What are the risk factors for pressure ulcer development?

• A. Immobility and poor nutrition
• B. Obesity and diabetes
• C. Dehydration and malnutrition
• D. Use of assistive devices and prolonged bedrest

Correct answer: A

Rationale: Corrected Rationale: The correct answer is immobility and poor nutrition. Immobility can lead to constant pressure on certain areas of the body, while poor nutrition can impair tissue repair and regeneration, both contributing to the development of pressure ulcers. Choices B, C, and D are incorrect because while obesity, diabetes, dehydration, malnutrition, use of assistive devices, and prolonged bedrest can impact skin integrity and wound healing, they are not the primary risk factors specifically associated with pressure ulcer development.

2. What is the correct way to assess for pitting edema?

• A. Press over the bony area for 5 seconds and release
• B. Press over the skin for 10 seconds and check for discoloration
• C. Press the area and check for the presence of rash
• D. Press the skin and assess for rebound tenderness

Correct answer: A

Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.

3. A nurse is reviewing the plan of care for a client who is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent venous thromboembolism?

• A. Instruct the client to perform ankle pumps
• B. Administer anticoagulant therapy as prescribed
• C. Maintain the client in a prone position
• D. Encourage the client to ambulate as tolerated

Correct answer: B

Rationale: The correct intervention to prevent venous thromboembolism in a postoperative client following hip replacement is to administer anticoagulant therapy as prescribed. Anticoagulants help prevent blood clots from forming. Instructing the client to perform ankle pumps helps prevent blood clots by promoting circulation. Maintaining the client in a prone position can increase the risk of venous stasis and thrombus formation. Encouraging the client to ambulate as tolerated also helps prevent venous thromboembolism by promoting blood flow and preventing stasis.

4. A healthcare professional is preparing to administer a blood transfusion. What is the healthcare professional's first action?

• A. Check the client's temperature
• B. Verify that the client's blood type matches the blood product
• C. Administer the blood through an IV push
• D. Ensure the blood is warmed before administration

Correct answer: B

Rationale: The healthcare professional's first action before administering a blood transfusion should be to verify that the client's blood type matches the blood product. This step is crucial to ensure compatibility and prevent potentially severe transfusion reactions. Checking the client's temperature (Choice A) is important but not the first action in this scenario. Administering the blood through an IV push (Choice C) is incorrect as blood transfusions are typically administered as a slow infusion. Ensuring the blood is warmed before administration (Choice D) is not the first action and is not a standard practice in blood transfusions.

5. What is the first intervention for a patient in shock?

• A. Administer fluids
• B. Monitor blood pressure
• C. Provide oxygen
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer fluids. In a patient experiencing shock, the priority is to address inadequate perfusion by restoring circulating blood volume. Administering fluids helps improve perfusion and oxygen delivery to vital organs. Monitoring blood pressure, providing oxygen, and calling for assistance are important steps but administering fluids is the initial and most critical intervention in the management of shock.

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