Nursing Elites

1. What is the primary action the nurse should take first for a client with a pressure ulcer who has a serum albumin level of 3 g/dL?

• A. Increase the protein intake in the diet
• B. Consult with a dietitian to create a high-protein diet
• C. Increase the IV fluid infusion rate
• D. Administer a protein supplement

Correct answer: B

Rationale: The correct answer is to consult with a dietitian to create a high-protein diet. A serum albumin level of 3 g/dL indicates hypoalbuminemia, which can impair wound healing. Consulting with a dietitian to optimize the client's protein intake is crucial in promoting wound healing for pressure ulcers. Increasing the protein intake in the diet (Choice A) may not be sufficient without proper guidance from a dietitian. Increasing the IV fluid infusion rate (Choice C) is not directly related to addressing the protein deficiency. Administering a protein supplement (Choice D) should be guided by a healthcare professional's recommendation after consulting with a dietitian.

2. When caring for a client with a wound infection, what is the most important nursing action?

• A. Change the dressing every 4 hours
• B. Perform a wound culture before administering antibiotics
• C. Cleanse the wound with alcohol-based solutions
• D. Apply a wet-to-dry dressing to the wound

Correct answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial in identifying the specific infecting organism and choosing the most effective antibiotic treatment. Changing the dressing every 4 hours (choice A) may be too frequent and can disrupt the wound healing process. Cleansing the wound with alcohol-based solutions (choice C) can be too harsh and may delay healing. Applying a wet-to-dry dressing (choice D) can cause trauma to the wound bed and is not recommended for infected wounds.

3. Which of the following interventions should the nurse implement for a client with dementia who is at risk of falling?

• A. Keep the bed in the lowest position
• B. Raise all four side rails to prevent falls
• C. Assist with ambulation every 2 hours
• D. Use a bed exit alarm to notify staff of attempts to leave the bed

Correct answer: D

Rationale: The correct intervention for a client with dementia at risk of falling is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention helps in preventing falls by alerting the staff when the client tries to get out of bed. Keeping the bed in the lowest position (Choice A) may not prevent falls and could make it challenging for staff to provide care. Raising all four side rails (Choice B) can be a restraint and is not recommended as it may lead to entrapment or other risks. Assisting with ambulation every 2 hours (Choice C) may not be feasible or effective in preventing falls, as the client may attempt to get out of bed at any time.

4. What are the common signs and symptoms of dehydration in the elderly?

• A. Dry mouth, confusion, and decreased skin turgor
• B. Increased heart rate and muscle cramps
• C. Fever, rapid breathing, and increased urine output
• D. Increased thirst and difficulty walking

Correct answer: A

Rationale: Corrected Rationale: Dehydration in the elderly is often signaled by dry mouth, confusion, and decreased skin turgor due to reduced fluid intake. Choice A is the correct answer as these are common signs and symptoms of dehydration in the elderly.\nIncorrect Rationales: Option B (Increased heart rate and muscle cramps) are more associated with conditions like hyperthyroidism or electrolyte imbalances rather than dehydration. Option C (Fever, rapid breathing, and increased urine output) are signs of other medical conditions such as infections or diabetes insipidus. Option D (Increased thirst and difficulty walking) can be seen in various situations but are not specific signs of dehydration in the elderly.

5. What are the early signs of DVT?

• A. Leg pain, swelling, and redness
• B. Shortness of breath and high fever
• C. Cough and chest pain
• D. Decreased oxygen saturation and low blood pressure

Correct answer: A

Rationale: The correct answer is A: Leg pain, swelling, and redness are early signs of DVT. DVT (Deep Vein Thrombosis) is a condition where blood clots form in deep veins, commonly in the legs. These clots can cause symptoms like pain, swelling, and redness in the affected leg. Choices B, C, and D describe symptoms more commonly associated with other conditions like pulmonary embolism (shortness of breath and high fever), respiratory issues (cough and chest pain), and cardiovascular problems (decreased oxygen saturation and low blood pressure), respectively. Therefore, they are not indicative of early signs of DVT.

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