Nursing Elites

1. While changing the pressure ulcer dressing of a client who is immobile, the nurse notes that the boundary edges of the wound have increased. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s serum laboratory values?

• A. Potassium
• B. Platelets
• C. Creatinine
• D. Albumin

Correct answer: D

Rationale: The correct answer is D: Albumin. Reviewing albumin levels is crucial in this situation because low albumin levels can impact wound healing and contribute to increased wound edges. Potassium (choice A) is not directly related to wound healing or wound edges. Platelets (choice B) are more related to blood clotting than wound healing. Creatinine (choice C) is related to kidney function, not specifically to wound healing or wound edges.

2. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

• A. Transport a client who is receiving IV fluid to the radiology department
• B. Administer PRN oral analgesics to a client with a history of chronic pain
• C. Supervise a newly hired graduate nurse during an admission assessment
• D. Complete ongoing focused assessments of a client with wrist restraints

Correct answer: C

Rationale: The correct answer is C because supervising a newly hired graduate nurse during an admission assessment is a task that falls within the registered nurse's scope of practice. Registered nurses are responsible for overseeing and delegating tasks, especially to new staff, to ensure proper assessment and care delivery. Choices A, B, and D involve tasks that can be appropriately assigned to practical nurses or unlicensed assistive personnel as they are within their scope of practice. Transporting a client, administering oral analgesics, and completing focused assessments do not require the advanced knowledge and skills of a registered nurse.

3. A client has a history of vasovagal attacks resulting in brady-dysrhythmias. Which instruction is most important to include in the teaching plan?

• A. Use stool softeners regularly
• B. Avoid electromagnetic fields
• C. Maintain a low-fat diet
• D. Do not use aspirin products

Correct answer: A

Rationale: The correct answer is A: 'Use stool softeners regularly.' Vasovagal attacks can be triggered by straining, and using stool softeners can help prevent such attacks. Choices B, C, and D are not directly related to preventing vasovagal attacks in this context. Avoiding electromagnetic fields, maintaining a low-fat diet, or not using aspirin products are important for various health reasons but not specifically for preventing vasovagal attacks related to brady-dysrhythmias.

4. During the administration of albuterol per nebulizer, the client complains of shakiness. The client’s vital signs are heart rate 120 beats/minute, respirations 20 breaths/minute, blood pressure 140/80. What action should the nurse take?

• A. Administer an anxiolytic
• B. Obtain a 12-lead electrocardiogram
• C. Stop the albuterol administration and restart in 30 minutes
• D. Educate the client about the side effects of albuterol

Correct answer: D

Rationale: Shakiness is a known side effect of albuterol, which can often be managed without the need for additional medications. Educating the client about the potential side effects of albuterol, including shakiness, helps them understand what to expect and how to manage these effects. Administering an anxiolytic (Choice A) is not indicated as shakiness related to albuterol is not a sign of anxiety. Obtaining a 12-lead electrocardiogram (Choice B) is not necessary based on the client's presentation of shakiness and vital signs. Stopping the albuterol administration and restarting in 30 minutes (Choice C) may not be necessary since shakiness is a common side effect that can often be managed without interrupting the treatment.

5. Following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of “a tingly sensation” in his left foot. The nurse determines the client’s left pedal pulses are diminished. Based on these findings, what is the client’s greatest risk?

• A. Reduce pulmonary ventilation and oxygenation related to fat embolism.
• B. Neurovascular and circulation compromise related to compartment syndrome.
• C. Wound infection and delayed healing due to fractured bone protrusion.
• D. Venous stasis and thrombophlebitis related to postoperative immobility.

Correct answer: B

Rationale: The correct answer is B. Compartment syndrome is a serious condition that can occur following trauma or surgery, leading to compromised neurovascular status in the affected limb. Symptoms include pain, paresthesia (tingling sensation), and diminished pulses. If left untreated, compartment syndrome can result in tissue damage and potential loss of limb function. Options A, C, and D are incorrect because they do not directly address the neurovascular compromise associated with compartment syndrome.

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