Nursing Elites

1. Which of the following findings should the nurse anticipate in the medical record of a client with a pressure ulcer?

• A. Serum albumin level of 3 g/dL
• B. Braden scale score of 20
• C. Norton scale score of 18
• D. Hemoglobin level of 13 g/dL

Correct answer: A

Rationale: The correct answer is A: Serum albumin level of 3 g/dL. A serum albumin level of 3 g/dL indicates poor nutrition, which is commonly seen in clients with pressure ulcers. Choice B, a Braden scale score of 20, is incorrect because a higher Braden scale score indicates a lower risk of developing pressure ulcers. Choice C, a Norton scale score of 18, is incorrect as it is a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer. Choice D, a hemoglobin level of 13 g/dL, is unrelated to pressure ulcers and does not directly reflect the nutritional status associated with this condition.

2. A client with IV fluids has developed redness and warmth at the IV site. What is the next step the nurse should take?

• A. Apply a cold compress to the IV site
• B. Discontinue the IV and notify the healthcare provider
• C. Monitor the IV site for signs of infection
• D. Increase the IV flow rate to improve circulation

Correct answer: B

Rationale: When a client develops redness and warmth at the IV site, it is indicative of phlebitis, which is inflammation of the vein. The next step for the nurse should be to discontinue the IV and notify the healthcare provider. Applying a cold compress may provide temporary relief but does not address the underlying issue. Monitoring for infection is important, but in this case, the presence of redness and warmth suggests phlebitis, not infection. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

3. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?

• A. Can you tell me who visited you today?
• B. What high school did you graduate from?
• C. Can you list your current medications?
• D. What did you have for breakfast yesterday?

Correct answer: B

Rationale: The correct answer is B: 'What high school did you graduate from?' Remote memory involves recalling past events, such as educational history, making option B the most appropriate question to assess this aspect of memory in an older adult with mild dementia. Option A pertains to recent memory. Option C focuses on short-term memory. Option D addresses recent memory as well.

4. What is the process for taking a telephone order from a provider?

• A. Patient name, drug, dose, route, frequency
• B. Read back for accuracy
• C. Have a witness listen to the order
• D. Write down the order and follow up

Correct answer: B

Rationale: The correct process for taking a telephone order from a provider involves reading back the information for accuracy. This step ensures that the order is correctly understood and reduces the risk of errors. While listing patient information (Choice A) is essential, it does not encompass the complete process of verifying the order. Having a witness listen to the order (Choice C) may not always be practical or necessary, as direct verification is more efficient. Writing down the order and following up (Choice D) is not as crucial as the immediate read-back process, which allows for real-time clarification and confirmation.

5. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client with pneumonia who had new onset of confusion
• B. A client with diabetes who had low blood sugar overnight
• C. A client with a leg fracture who needs pain medication
• D. A client whose urinary output was 100 mL for the past 12 hours

Correct answer: A

Rationale: The correct answer is A. New confusion in a client with pneumonia could indicate hypoxia or a worsening condition, requiring immediate attention. Option B, a client with diabetes having low blood sugar overnight, is a concerning condition but not as urgent as potential hypoxia. Option C, a client with a leg fracture needing pain medication, and option D, a client with decreased urinary output, are important but do not take precedence over addressing a potentially critical respiratory issue.

Similar Questions