Nursing Elites

1. While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?

• A. Tinea corporis
• B. Herpes zoster
• C. Psoriasis
• D. Drug reaction

Correct answer: C

Rationale: The correct answer is C, Psoriasis. Psoriasis commonly presents with well-circumscribed, silvery scales and plaques, typically found on extensor surfaces like elbows and knees. Tinea corporis (A) presents as a circular rash, herpes zoster (B) presents as a painful rash following a dermatomal pattern, and drug reactions (D) have variable presentations not specific to elbows and knees with silvery scales and plaques.

2. The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

• A. Medication port
• B. IV drip chamber
• C. Y-site connector
• D. At the hub of the IV catheter

Correct answer: A

Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.

3. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding requires immediate intervention?

• A. Elevated blood pressure
• B. Increased fatigue
• C. Headache
• D. Elevated hemoglobin

Correct answer: A

Rationale: The correct answer is A: Elevated blood pressure. In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure requires immediate intervention. This finding is concerning as it may indicate worsening hypertension, which can lead to further complications. Increased fatigue (choice B) is common in CKD but may not require immediate intervention unless severe. Headache (choice C) can be a symptom to monitor but does not pose an immediate threat like elevated blood pressure. Elevated hemoglobin (choice D) is actually a desired outcome of erythropoietin therapy and does not require immediate intervention.

4. The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which intervention should the nurse implement first?

• A. Encourage fluid intake to thin secretions.
• B. Administer a mucolytic agent.
• C. Increase humidity in the client's room.
• D. Perform deep suctioning as needed.

Correct answer: C

Rationale: Increasing humidity in the client's room is the first priority in managing thick, tenacious secretions in a client with a tracheostomy to facilitate airway clearance. This intervention helps to moisten secretions, making them easier to clear. Encouraging fluid intake (Choice A) can be beneficial, but increasing humidity should be addressed first. Administering a mucolytic agent (Choice B) and performing deep suctioning (Choice D) are interventions that can be considered after addressing humidity if necessary, but they are not the initial priority.

5. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding is most concerning?

• A. Increased fatigue
• B. Elevated blood pressure
• C. Low urine output
• D. Elevated hemoglobin

Correct answer: B

Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, an elevated blood pressure is the most concerning assessment finding. Elevated blood pressure can indicate worsening hypertension, which requires immediate intervention. Increased fatigue may be expected due to anemia associated with CKD and erythropoietin therapy. Low urine output may indicate impaired kidney function but is not as immediately concerning as elevated blood pressure. Elevated hemoglobin levels are the desired outcome of erythropoietin therapy, indicating an appropriate response to treatment.

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