Nursing Elites

1. While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?

• A. A 79-year-old malnourished client on bed rest
• B. An obese client who uses a wheelchair
• C. A client who had 3 incontinent diarrhea stools
• D. An 80-year-old ambulatory diabetic client

Correct answer: A

Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to poor nutrition and immobility. Malnutrition can impair tissue healing and increase susceptibility to skin breakdown, while prolonged bed rest can lead to pressure ulcers. Choice B is incorrect because obesity can cushion pressure points and reduce the risk of pressure ulcers. Choice C is incorrect as incontinence predisposes to moisture-associated skin damage rather than pressure ulcers. Choice D is incorrect as an ambulatory client is less likely to develop pressure ulcers compared to bedridden clients.

2. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?

• A. I use a sliding scale to adjust regular insulin to my sugar level.
• B. Since my eyesight is so bad, I ask the nurse to fill several syringes.
• C. I keep my regular insulin bottle in the refrigerator.
• D. I always make sure to shake the NPH bottle hard to mix it well.

Correct answer: D

Rationale: Shaking the NPH insulin bottle hard can cause air bubbles and affect dosing accuracy; it should be rolled gently instead.

3. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?

• A. Cut the child's hair short to remove the nits
• B. Apply warm soaks to the head twice daily
• C. Wash the child's linen and clothing in a bleach solution
• D. Application of pediculicides

Correct answer: D

Rationale: Pediculicides are the recommended treatment for lice and should be used to eliminate the infestation.

4. During an assessment on a client in congestive heart failure, what is most likely to be revealed upon auscultation of the heart?

• A. S3 ventricular gallop
• B. Apical click
• C. Systolic murmur
• D. Split S2

Correct answer: A

Rationale: The correct answer is A: S3 ventricular gallop. An S3 sound is a common finding in congestive heart failure due to fluid overload in the heart. It is associated with decreased ventricular compliance. Choices B, C, and D are incorrect. An apical click is not typically associated with congestive heart failure. A systolic murmur may be heard in conditions like mitral regurgitation but is not specific to congestive heart failure. A split S2 is associated with conditions like pulmonary hypertension, not congestive heart failure.

5. An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?

• A. Assess the severity and location of the pain
• B. Obtain an order for an analgesic
• C. Reassure the client that this is not unusual for his age
• D. Encourage the client to increase activity

Correct answer: A

Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.

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