Nursing Elites

1. A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer.

• A. Intact skin with nonblanchable redness (Stage 1)
• B. Full-thickness tissue loss with subQ damage (Stage 3)
• C. Partial-thickness skin loss involving the epidermis and dermis
• D. Full-thickness tissue loss with damage to muscle or bone (Stage 4)

Correct answer: C

Rationale: The correct answer is C. Stage 2 ulcers involve partial-thickness skin loss with visible and superficial damage, which may appear as an abrasion, blister, or shallow crater. Choice A describes a Stage 1 pressure ulcer characterized by intact skin with nonblanchable redness. Choice B describes a Stage 3 pressure ulcer with full-thickness tissue loss and damage to the subcutaneous tissue. Choice D is indicative of a Stage 4 pressure ulcer, involving full-thickness tissue loss with damage extending to muscle or bone.

2. What is the nurse's next action after a laboring client's membranes have just ruptured?

• A. Assess fetal heart rate pattern
• B. Monitor uterine contractions
• C. Administer oxygen
• D. Prepare for delivery

Correct answer: A

Rationale: After a laboring client's membranes have ruptured, the nurse's immediate priority is to assess the fetal heart rate pattern. This assessment is crucial to ensure the fetus is not in distress, especially to rule out umbilical cord compression that could affect blood flow to the fetus. While monitoring uterine contractions is important, assessing the fetal heart rate takes precedence in this situation as it directly reflects the fetus's well-being. Administering oxygen may be necessary later depending on the fetal status, and preparing for delivery should only occur if the assessment indicates fetal distress or other complications. Therefore, the correct next action for the nurse is to assess the fetal heart rate pattern.

3. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?

• A. Bounding pulse
• B. Conjunctival pallor
• C. Elevated blood pressure
• D. Glossitis

Correct answer: B

Rationale: The correct answer is B: Conjunctival pallor. In anemia, there is a decrease in hemoglobin levels, leading to paleness of the conjunctiva. This is a common finding in individuals with anemia. Bounding pulse (choice A) is not typically associated with anemia but can be seen in conditions like hyperthyroidism. Elevated blood pressure (choice C) is not a common finding in anemia; instead, blood pressure may be low due to decreased oxygen-carrying capacity. Glossitis (choice D), or a swollen tongue, can be seen in certain types of anemia but is not as specific or common as conjunctival pallor.

4. When resolving a conflict, which statement made by the charge nurse is an example of smoothing?

• A. You have been a nurse a long time, so I’m sure you’re capable of the tasks.
• B. If you prefer, I can take over your assignment.
• C. We can switch your assignment with someone else.
• D. Let’s discuss your concerns in a private setting.

Correct answer: A

Rationale: The correct answer is A because it exemplifies smoothing, a conflict resolution strategy where the charge nurse reassures the staff nurse of their capabilities. Choice B offers to take over the assignment, which is more of a compromising strategy. Choice C suggests switching assignments, which aligns with compromising rather than smoothing. Choice D proposes a discussion in a private setting, indicating a collaborating approach rather than smoothing.

5. A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states:

• A. I will make sure my medications are enteric-coated
• B. My stoma will drain liquid continuously
• C. I will change my pouch system every two weeks
• D. My stoma size will stay the same after it heals

Correct answer: B

Rationale: The correct answer is B. When a client with an ileostomy states that their stoma will drain liquid continuously, it indicates an understanding of the expected outcome. In an ileostomy, the stoma continuously drains liquid stool as it bypasses the large intestine where water is absorbed. Choices A, C, and D are incorrect because ensuring medications are enteric-coated, changing the pouch system every two weeks, and expecting the stoma size to remain the same after healing are not accurate statements related to an ileostomy.

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