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. A healthcare professional is collecting data from a client who has hypokalemia. Which of the following findings should the healthcare professional expect?

• A. Muscle stiffness
• B. Bradycardia
• C. Hyperreflexia
• D. Muscle weakness

Correct answer: D

Rationale: The correct answer is 'Muscle weakness.' Hypokalemia is characterized by low potassium levels, which can lead to muscle weakness due to impaired muscle function. Choices A, B, and C are incorrect findings associated with other medical conditions and not typically expected in hypokalemia. Muscle stiffness is more commonly associated with conditions like tetany or muscle cramps, bradycardia is more commonly associated with issues like heart block or hypothyroidism, and hyperreflexia is more commonly seen in conditions like hyperthyroidism or spinal cord injuries.

3. A healthcare provider is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the provider report?

• A. White blood cell count of 8,000/mm³
• B. Potassium level of 4.0 mEq/L
• C. Creatinine level of 1.0 mg/dL
• D. Hemoglobin level of 12 g/dL

Correct answer: C

Rationale: An elevated creatinine level indicates impaired kidney function, which may affect the client's ability to undergo surgery. The other laboratory values (white blood cell count, potassium level, and hemoglobin level) are within normal ranges and do not directly impact the client's readiness for surgery.

4. A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?

• A. Abdominal pain radiating to the right shoulder.
• B. Absent bowel sounds.
• C. Brown drainage on the surgical dressing.
• D. Urine output of 25 mL/hr.

Correct answer: D

Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.

5. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

• A. A history of gastroesophageal reflux disease.
• B. Receiving a formula with high osmolarity.
• C. Sitting in a high-Fowler's position during the feeding.
• D. A residual of 65 mL 1 hour postprandial.

Correct answer: A

Rationale: The correct answer is A: A history of gastroesophageal reflux disease. Clients with gastroesophageal reflux disease have a higher risk of aspiration during tube feeding due to the potential for reflux of stomach contents into the lungs. This increases the risk of aspiration pneumonia. Choices B, C, and D are incorrect. High osmolarity formulas may cause diarrhea but do not directly increase the risk of aspiration. Sitting in a high-Fowler's position actually reduces the risk of aspiration by promoting proper digestion and reducing the chance of regurgitation. A residual of 65 mL 1 hour postprandial is within an acceptable range and does not directly indicate a risk for aspiration.

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