Nursing Elites

1. A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:

• A. Within normal limits, so a weight-reduction diet is unnecessary.
• B. Lower than normal, so education about nutrient-dense foods is needed.
• C. Indicating obesity because the BMI is 35.
• D. Indicating overweight status because the BMI is 27.

Correct answer: C

Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. Body Mass Index (BMI) is calculated by utilizing a chart or nomogram that plots height and weight. In this case, the client's BMI is calculated as 35, indicating obesity. A BMI of 27 falls within the overweight range, not obesity (which starts at 30). Choices A and B are incorrect because a BMI of 35 indicates obesity, not normal limits or being lower than normal. Therefore, the correct answer is C, indicating obesity based on the BMI calculation.

2. The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?

• A. irregular respirations
• B. abdominal respirations
• C. shallow respirations
• D. 70 breaths per minute

Correct answer: D

Rationale: The ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. Therefore, a rate of 70 breaths per minute would necessitate follow-up and further intervention. Irregular, abdominal, and shallow respirations are common in newborns and may not necessarily indicate the need for immediate follow-up or intervention.

3. A person who had a left CVA and right lower extremity hemiparesis is being instructed by a nurse to use a quad cane. Which of the following is the most appropriate gait sequence?

• A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
• B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
• C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
• D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.

Correct answer: A

Rationale: The correct gait sequence for a person with left CVA and right lower extremity hemiparesis using a quad cane is to place the cane in the patient's strong upper extremity, which is the left upper extremity in this case. The correct sequence should be right lower extremity followed by left upper extremity, as this pattern mimics a normal gait pattern. Therefore, Choice A is the correct answer. Choices B, C, and D are incorrect because they do not follow the proper gait sequence for this specific patient's condition. The cane should be placed in the strong upper extremity, and the affected lower extremity should move first to provide stability and support, which is essential in this situation.

4. What is a chemical reaction between drugs before their administration or absorption known as?

• A. a drug incompatibility
• B. a side effect
• C. an adverse event
• D. an allergic response

Correct answer: A

Rationale: A chemical reaction between drugs before their administration or absorption is termed a drug incompatibility. This phenomenon commonly happens when drug solutions are mixed before intravenous administration, but it can also occur with orally administered drugs. Choices B, C, and D are incorrect because side effects, adverse events, and allergic responses occur after the administration and absorption of drugs, not prior to it.

5. While performing wound care to a donor skin graft site, the nurse notes some scabbing at the edges and a black collection of blood. What is the nurse's next action?

• A. Leave the scabbed area alone and apply extra ointment
• B. Notify the physician
• C. Gently remove the debris and re-dress the wound
• D. Apply skin softening lotion for 3 hours and then re-dress

Correct answer: C

Rationale: When the nurse notes scabbing at the edges and a black collection of blood, it indicates the presence of debris that needs to be addressed. Leaving the scabbed area alone and applying extra ointment may not address the underlying issue and could lead to complications. Notifying the physician is important in some cases, but immediate action is required to prevent infection in this situation. Gently removing the debris and re-dressing the wound is the correct course of action to promote healing and prevent complications.

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