a client with a serum albumin level of 3 gdl has a pressure ulcer what should the nurse do first

ATI LPN

ATI NCLEX PN Predictor Test

1. A client with a serum albumin level of 3 g/dL has a pressure ulcer. What should the nurse do first?

A. Monitor the client's fluid and electrolyte balance
B. Consult a dietitian to improve the client's nutritional status
C. Administer a protein supplement
D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.

2. A client who is to undergo a colonoscopy is being taught by a nurse about the procedure. Which of the following statements by the client indicates an understanding of the teaching?

A. I will drink liquids right up until the procedure.
B. I will need to stop eating and drinking at least 24 hours before the procedure.
C. I will be sedated and will not feel any pain during the procedure.
D. I will not need to follow any specific dietary restrictions for this procedure.

Correct answer: C

Rationale: Choice C is the correct answer. During a colonoscopy, clients are typically sedated, so they do not feel any pain during the procedure. Choices A, B, and D are incorrect. Clients are usually required to stop eating and drinking at least 24 hours before a colonoscopy, and there are specific dietary restrictions that need to be followed before the procedure to ensure a successful examination.

3. A client is receiving IV fluids and has developed phlebitis. What is the next step the nurse should take?

A. Monitor the site for further swelling
B. Remove the catheter and place it in another site
C. Reduce the flow rate of IV fluids
D. Switch to oral hydration

Correct answer: B

Rationale: The correct next step when a client develops phlebitis while receiving IV fluids is to remove the catheter and place it in another site. Phlebitis is inflammation of a vein, and leaving the catheter in the same site can lead to further complications. Monitoring the site for further swelling, as in choice A, is not enough as the source of inflammation needs to be removed. Choice C, reducing the flow rate, may not address the underlying issue causing phlebitis. Switching to oral hydration, as in choice D, is not necessary for addressing phlebitis related to IV fluid administration.

4. What are the major risk factors for stroke?

A. Hypertension, high cholesterol, and smoking
B. Obesity and lack of exercise
C. Family history of cardiovascular disease
D. Age and gender

Correct answer: A

Rationale: The correct answer is A: Hypertension, high cholesterol, and smoking are major risk factors for stroke. These factors contribute to the development of atherosclerosis, which can lead to a stroke. While obesity and lack of exercise are risk factors for cardiovascular diseases, they are not as directly linked to stroke as hypertension, high cholesterol, and smoking. Family history of cardiovascular disease may increase the overall risk of heart problems, but it is not as specific to stroke as the factors listed in option A. Age and gender can influence the risk of stroke, but they are not modifiable risk factors like hypertension, high cholesterol, and smoking, which can be reduced through lifestyle changes.

5. What are the key differences between systolic and diastolic heart failure?

A. Systolic: Reduced ejection fraction; Diastolic: Preserved ejection fraction
B. Systolic: Preserved ejection fraction; Diastolic: Reduced ejection fraction
C. Systolic: Right-sided heart failure; Diastolic: Left-sided heart failure
D. Systolic: Pulmonary congestion; Diastolic: Systemic congestion

Correct answer: A

Rationale: The correct answer is A. Systolic heart failure is characterized by reduced ejection fraction, meaning the heart is not pumping effectively. Diastolic heart failure, on the other hand, is characterized by preserved ejection fraction, indicating that the heart has difficulty relaxing and filling properly. Choices B, C, and D are incorrect because they do not accurately describe the key differences between systolic and diastolic heart failure.