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 receives a report from assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Notify the provider
• B. Recheck the blood pressure
• C. Administer antihypertensive medication
• D. Document the blood pressure in the chart

Correct answer: B

Rationale: The correct first action for the nurse to take when receiving a report of a client's blood pressure reading of 160/95 is to recheck the blood pressure. Rechecking the blood pressure ensures the accuracy of the reading before making any further decisions or interventions. Notifying the provider (Choice A) can be considered after confirming the blood pressure reading. Administering antihypertensive medication (Choice C) should not be done based solely on one reading without verification. Documenting the blood pressure in the chart (Choice D) should also come after confirming the accuracy of the reading to avoid recording incorrect information.

3. A nurse is caring for a client who is receiving continuous enteral feedings. What finding indicates intolerance to the feeding?

• A. Weight gain
• B. Nausea
• C. Constipation
• D. Elevated heart rate

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Weight gain is not typically associated with intolerance to enteral feedings; instead, it may indicate other issues such as fluid retention. Constipation is also not a direct indicator of intolerance to enteral feedings. While an elevated heart rate can occur for various reasons, it is less specific to enteral feeding intolerance compared to nausea.

4. 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.

5. A nurse is caring for a client who is postoperative following cataract surgery. The client reports that they do not want to wear their eye shield. What should the nurse do?

• A. Allow the client to make their own decision
• B. Explain the importance of wearing the eye shield
• C. Remove the eye shield and assess the eye
• D. Encourage the client to discuss their concerns

Correct answer: B

Rationale: The correct answer is B: Explain the importance of wearing the eye shield. It is important for the nurse to educate the client on the reasons why wearing the eye shield is crucial post cataract surgery, such as protecting the eye from injury and promoting proper healing. This empowers the client with knowledge and helps them make an informed decision. Choice A is incorrect because the nurse should provide necessary information to ensure the client's safety. Choice C is incorrect as removing the eye shield without proper justification can compromise the client's recovery. Choice D is also incorrect as discussing concerns should come after the client is educated on the importance of the eye shield.

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