Nursing Elites

1. A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client’s plan of care?

• A. High risk for infection related to subclavian catheter
• B. High risk of injury related to ambulation
• C. Knowledge deficit related to a high-protein diet
• D. Hygiene self-care deficit related to uremic frost

Correct answer: D

Rationale: The correct answer is D. Uremic frost is a condition in which urea and other waste products are excreted through the skin, leaving a powdery residue. This indicates poor hygiene and self-care, common issues in patients with CKD and renal osteodystrophy. Proper hygiene measures are essential to prevent complications. Choices A, B, and C are less likely to be included in the plan of care for a CKD patient with renal osteodystrophy. Choice A is more related to a vascular access issue, choice B is more related to mobility concerns, and choice C is more related to dietary education.

2. The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique?

• A. Remove old dressing using clean gloves. Discard gloves with old dressing
• B. Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area
• C. Apply sterile gauze dressing to wound area
• D. Secure dressing with tape

Correct answer: A

Rationale: The correct order ensures proper aseptic technique and wound care to prevent infection. The first step is to remove the old dressing using clean gloves to prevent contamination. Discarding the gloves with the old dressing helps maintain cleanliness. Choices B, C, and D are incorrect because cleaning the wound, applying a new dressing, and securing it should come after removing the old dressing to maintain asepsis and prevent infection.

3. What nursing intervention is particularly indicated for the second stage of labor?

• A. Providing pain medication to increase the client’s tolerance of labor
• B. Assessing the fetal heart rate and pattern for signs of fetal distress
• C. Monitoring effects of oxytocin administration to help achieve cervical dilation
• D. Assisting the client to push effectively so that the expulsion of the fetus can be achieved

Correct answer: D

Rationale: During the second stage of labor, assisting the client to push effectively is crucial for the delivery of the fetus. This action helps to facilitate the expulsion of the fetus from the uterus. Providing pain medication (Choice A) is not typically done during the second stage of labor as the focus shifts to pushing and delivery. Assessing the fetal heart rate (Choice B) is important but is more relevant throughout labor, not specifically for the second stage. Monitoring the effects of oxytocin administration (Choice C) is more associated with the first stage of labor to help with uterine contractions and cervical dilation.

4. Which client’s vital signs indicate increased intracranial pressure (ICP) that the nurse should report to the healthcare provider?

• A. P 70, BP 120/60 mmHg; P 100, BP 90/60 mmHg; rapid respirations.
• B. P 55, BP 160/70 mmHg; P 50, BP 194/70 mmHg; irregular respirations.
• C. P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations.
• D. P 110, BP 130/70 mmHg; P 100, BP 110/70 mmHg; shallow respirations.

Correct answer: C

Rationale: Choice C is the correct answer. The vital signs presented (P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations) indicate increased intracranial pressure (ICP), which can be a serious condition requiring immediate medical attention. Kussmaul respirations are deep and labored breathing patterns associated with metabolic acidosis and can be a late sign of increased ICP. Choices A, B, and D do not demonstrate vital sign patterns consistent with increased ICP. Choice A shows variations in blood pressure and pulse rate but does not provide a clear indication of increased ICP. Choice B displays fluctuations in blood pressure and pulse rate with irregular respirations, but these vital signs do not specifically suggest increased ICP. Choice D presents relatively stable vital signs with shallow respirations, which do not align with the typical vital signs seen in increased ICP.

5. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply)

• A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)
• B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
• C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
• D. Initiate patient-controlled analgesia (PCA) pumps for two clients immediately postoperative

Correct answer: B

Rationale: The correct answer is B. Obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a task within the scope of practice for a practical nurse (PN) and contributes to the client's recovery. Administering insulin (Choice A) involves medication administration, which typically requires a higher level of nursing education. Performing daily surgical dressing changes (Choice C) after an abdominal hysterectomy involves wound care management that is usually beyond the scope of practice for a PN. Initiating patient-controlled analgesia pumps (Choice D) is a complex nursing intervention that requires specialized training and knowledge, exceeding the typical responsibilities of a PN.

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