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. A healthcare professional is assessing a client for signs of hypoglycemia. Which of the following findings should the healthcare professional look for?

• A. Increased thirst
• B. Fatigue
• C. Weight gain
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Fatigue. Fatigue, along with symptoms like shakiness and irritability, are common signs of hypoglycemia. Increased thirst (Choice A) is more indicative of hyperglycemia. Weight gain (Choice C) is not typically associated with hypoglycemia. Elevated blood pressure (Choice D) is not a common sign of hypoglycemia.

3. Which of the following would increase a client's risk of ovarian cancer?

• A. History of fibroids
• B. Early menopause
• C. Endometriosis
• D. Polycystic ovary syndrome

Correct answer: C

Rationale: The correct answer is C, Endometriosis. Endometriosis is associated with an increased risk of developing ovarian cancer due to chronic inflammation and hormonal imbalances. The exact cause is not fully understood, but women with endometriosis should be monitored closely. Choices A, B, and D are incorrect as they are not directly linked to an increased risk of ovarian cancer. Fibroids, early menopause, and polycystic ovary syndrome do not have a known direct correlation with ovarian cancer risk.

4. A healthcare provider is providing education on the use of atorvastatin. Which of the following should be included?

• A. Monitor for liver function
• B. It can cause muscle pain
• C. It is safe to take during pregnancy
• D. Both A and B

Correct answer: D

Rationale: Atorvastatin requires monitoring for liver function due to its potential to cause liver abnormalities. It can also lead to muscle pain or weakness, a condition known as myopathy. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus, making choices A and B the correct options to include in patient education.

5. A client is receiving enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse?

• A. Expel any air bubbles from the prefilled syringe
• B. Massage the injection site to aid in absorption of the medication
• C. Inject the medication into the lateral abdominal wall
• D. Administer an NSAID for injection site discomfort

Correct answer: C

Rationale: The correct answer is to inject enoxaparin into the lateral abdominal wall for subcutaneous absorption. This site is commonly used for administering this type of medication. Expelling air bubbles from the syringe is not necessary and may result in a reduced dose being administered. Massaging the injection site is not recommended as it can lead to bruising or irritation. Administering an NSAID for injection site discomfort is not indicated as discomfort at the injection site is usually minimal and self-limiting.

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