Nursing Elites

1. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

• A. Frequent repositioning
• B. Poor nutrition
• C. Increased fluid intake
• D. Use of a special mattress

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

2. A nurse is preparing to perform an abdominal assessment on a client. Which action should the nurse take first?

• A. Percuss the abdomen
• B. Inspect the abdomen
• C. Auscultate before palpation
• D. Palpate the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation. This ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen is a valid step but not the first. Percussing and palpating should come after auscultation to prevent altering bowel sounds or causing discomfort to the client.

3. A nurse is assessing a client who reports pain and redness at the site of a peripheral IV. What should the nurse do first?

• A. Apply a cold compress to the site
• B. Discontinue the IV line
• C. Notify the provider
• D. Increase the IV flow rate

Correct answer: B

Rationale: When a client reports pain and redness at the site of a peripheral IV, indicating signs of phlebitis, the nurse's initial action should be to discontinue the IV line. This helps prevent further complications and ensures patient safety. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider (Choice C) is important but not the initial step. Increasing the IV flow rate (Choice D) can exacerbate the inflammation and should be avoided.

4. A nurse is caring for a client who is postoperative following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?

• A. Increased physical activity
• B. Frequent urge suppression
• C. Adequate sleep
• D. Increased fluid intake

Correct answer: B

Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt the normal bowel movement pattern and lead to constipation. Choices A, C, and D are behaviors that generally help prevent constipation rather than increase the risk. Increased physical activity, adequate sleep, and increased fluid intake promote bowel regularity and reduce the risk of constipation.

5. A nurse is reviewing the medical records of a group of older adult clients. Which risk factor should the nurse identify as placing older adults at an increased risk for infections?

• A. Improved nutritional status
• B. Increased mobility
• C. Chronic conditions
• D. Lowered immune function

Correct answer: D

Rationale: The correct answer is D: Lowered immune function. Older adults often experience a decline in immune function as they age, making them more vulnerable to infections. This weakened immune system can result in increased susceptibility to various pathogens. Choice A, 'Improved nutritional status,' is incorrect because good nutrition can actually help support the immune system. Choice B, 'Increased mobility,' is not directly related to an increased risk of infections. Choice C, 'Chronic conditions,' while they can contribute to a weakened immune system, do not directly address the primary risk factor for infections in older adults.

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