Nursing Elites

1. Which structures are located in the subcutaneous layer of the skin?

• A. Sebaceous and sweat glands
• B. Melanin and keratin
• C. Sensory receptors and hair follicles
• D. Adipose cells and blood vessels

Correct answer: D

Rationale: The correct answer is D: Adipose cells and blood vessels. The subcutaneous layer, also known as the hypodermis, primarily consists of adipose (fat) tissue and blood vessels. Adipose tissue provides insulation, energy storage, and cushioning, while blood vessels supply nutrients and oxygen. Sebaceous and sweat glands are located in the dermis, which is the layer beneath the epidermis. Melanin and keratin are components of the epidermis, responsible for skin color and waterproofing, respectively. Sensory receptors and hair follicles are found in the dermis and extend into the subcutaneous layer but are not exclusive to it.

2. The nurse is assessing a client with chronic liver disease. Which lab value is most concerning?

• A. Elevated AST and ALT levels
• B. Decreased albumin level
• C. Elevated bilirubin level
• D. Prolonged PT/INR

Correct answer: D

Rationale: In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This finding indicates impaired liver function affecting the synthesis of clotting factors, leading to an increased risk of bleeding. Elevated AST and ALT levels (Choice A) indicate liver cell damage but do not directly correlate with the risk of bleeding. A decreased albumin level (Choice B) is common in liver disease but is not the most concerning in terms of bleeding risk. Elevated bilirubin levels (Choice C) are seen in liver disease but do not directly reflect the risk of bleeding as PT/INR values do.

3. A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's priority action?

• A. Continue the transfusion at a slower rate
• B. Administer an antipyretic
• C. Stop the transfusion immediately
• D. Notify the healthcare provider

Correct answer: C

Rationale: When a client receiving a blood transfusion reports chills and back pain, it indicates a possible transfusion reaction. The nurse's priority action is to stop the transfusion immediately. Continuing the transfusion at a slower rate (Choice A) can exacerbate the reaction. Administering an antipyretic (Choice B) may help with fever but does not address the underlying issue of a transfusion reaction. Notifying the healthcare provider (Choice D) is important but should not delay the immediate action of stopping the transfusion to ensure the client's safety.

4. The nurse is monitoring a client with an IV infusion in the left antecubital fossa. The site is warm, red, and without swelling. What conclusion should the nurse draw from these findings?

• A. The IV fluids are infusing into the subcutaneous tissues
• B. The infusion pump is functioning properly
• C. The insertion date should be verified and the IV discontinued
• D. The site is inflamed and should be reported

Correct answer: B

Rationale: The correct answer is B. Warmth and redness at the IV site without swelling indicate a localized reaction, which is common and does not necessarily indicate infiltration of IV fluids into the subcutaneous tissues. The absence of swelling suggests that the IV is correctly placed. Therefore, the nurse should conclude that the infusion pump is functioning properly. Choice A is incorrect as warmth and redness alone do not indicate subcutaneous infiltration. Choice C is incorrect as discontinuing the IV solely based on warmth and redness without swelling is not necessary. Choice D is incorrect as the absence of swelling signifies a localized reaction rather than inflammation requiring immediate reporting.

5. A hospitalized toddler who is recovering from a sickle cell crisis holds a toy and says, 'Mine.' According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage?

• A. Autonomy vs. Shame and Doubt
• B. Industry vs. Inferiority
• C. Initiative vs. Guilt
• D. Trust vs. Mistrust

Correct answer: A

Rationale: The toddler's behavior of asserting possession ('Mine') reflects a desire for independence, aligning with Erikson's stage of Autonomy vs. Shame and Doubt. This stage, typical for toddlers aged 1-3 years, focuses on developing a sense of control and independence. Choices B, C, and D are incorrect: Industry vs. Inferiority relates to middle childhood, Initiative vs. Guilt pertains to preschoolers, and Trust vs. Mistrust is associated with infancy.

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