Nursing Elites

1. A client in a long-term care facility has developed reddened skin over the sacrum, which has cracked and started to blister. The nurse confirms that the client has not been assisted with turning while in bed. Which stage of pressure ulcer is this client exhibiting?

• A. Stage I
• B. Stage II
• C. Stage III
• D. Stage IV

Correct answer: B

Rationale: The client is exhibiting a stage II pressure ulcer. A stage II pressure ulcer develops as a partial thickness wound that affects both the epidermis and the dermal layers of skin. This stage can present with red skin, blisters, or cracking, appearing shallow and moist. However, the ulcer does not extend to the underlying tissues at this stage. Choice A (Stage I) is incorrect as Stage I ulcers involve non-blanchable redness of intact skin. Choices C (Stage III) and D (Stage IV) are incorrect as they involve more severe tissue damage, extending into deeper layers of the skin and underlying tissues, which is not the case in this scenario.

2. A patient in a clinic has been diagnosed with hepatitis A. What is the most likely route of transmission?

• A. Sexual contact with an infected partner
• B. Contaminated food
• C. Blood transfusion
• D. Illegal drug use

Correct answer: B

Rationale: The correct answer is contaminated food. Hepatitis A is primarily transmitted through the fecal-oral route, often through the ingestion of contaminated food or water. It is caused by the Hepatitis A virus (HAV), which is a single-stranded, positive-sense RNA virus. Sexual contact with an infected partner is more commonly associated with hepatitis B and C. Blood transfusion is a potential route for hepatitis B and C transmission due to bloodborne pathogens. Illegal drug use, particularly involving shared needles, is a common route for hepatitis C transmission.

3. A patient has come to the office for a blood draw. The patient starts to sweat and is very anxious. Which of the following would be the BEST way to proceed?

• A. Do not perform the procedure. Notify the physician of the reason why.
• B. Perform the procedure but pay close attention for signs of potential syncope.
• C. Allow the patient to reschedule for a time when he isn't as anxious.
• D. Have the physician draw the blood.

Correct answer: B

Rationale: In the scenario where a patient is sweating and anxious, it is important to assess for signs of potential syncope (fainting) while proceeding with the blood draw. If the patient does not exhibit signs of fainting, the phlebotomy procedure can be performed safely. Postponing the procedure may not address the patient's anxiety and inconvenience them. Having the physician draw the blood is not necessary if the phlebotomist can handle the situation effectively.

4. When educating a client about their new prescription for warfarin, what should the nurse advise?

• A. To have his white blood cell count tested once a month
• B. To avoid any activities that could lead to injury
• C. To avoid eating leafy green vegetables
• D. Both A and B

Correct answer: B

Rationale: The correct answer is to advise the client to avoid any activities that could lead to injury when taking warfarin. Warfarin is an anticoagulant medication that decreases blood clotting, increasing the risk of bleeding. Engaging in activities that may result in injury can lead to uncontrolled bleeding, which can be serious. While monitoring white blood cell count is not specifically related to warfarin therapy, avoiding leafy green vegetables is important due to their vitamin K content, which can interfere with warfarin's effectiveness. Therefore, the client should be educated to avoid activities that could cause injury to prevent potential bleeding complications.

5. Patients have a right to ______________.

• A. only enough information so they can comply with care
• B. ALL of their health-related information
• C. small amounts of information so they do not get nervous
• D. moderate amounts of information unless they are old

Correct answer: B

Rationale: Patients have a legal right to access all of their health-related information. This includes details about their health condition, treatment options, test results, and any other relevant data. Providing patients with all their health-related information empowers them to make informed decisions about their care, promotes transparency in the healthcare process, and respects their autonomy. Choices A, C, and D are incorrect because they restrict the information patients should receive based on assumptions or limitations, which goes against the principle of patient autonomy and their right to access their complete health-related information.

Similar Questions