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1. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?
- A. Serum albumin level of 3 g/dL
- B. HDL level of 90 mg/dL
- C. Norton scale score of 18
- D. Braden scale score of 20
Correct answer: A
Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, which is commonly associated with pressure ulcers. This finding suggests that the client may be at risk for developing or already has a pressure ulcer due to malnutrition. High-density lipoprotein (HDL) level of 90 mg/dL (Choice B) is not directly related to pressure ulcers. The Norton scale (Choice C) is used to assess a client's risk of developing pressure ulcers, not as a finding in a client with an existing pressure ulcer. The Braden scale (Choice D) is also a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer.
2. A nurse is providing teaching to a client who is to start taking digoxin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I will contact my provider if my heart rate is below 60 beats per minute.
- C. I should take an antacid with this medication to prevent gastrointestinal upset.
- D. I will need to take this medication for 14 days.
Correct answer: B
Rationale: The client should contact their provider if their heart rate drops below 60 beats per minute, as this could indicate digoxin toxicity.
3. What is the priority intervention when managing a client with delirium?
- A. Administer antipsychotic medication to calm the client
- B. Identify any reversible causes of delirium
- C. Provide a low-stimulation environment
- D. Administer sedative medication to control agitation
Correct answer: B
Rationale: The correct answer is to identify any reversible causes of delirium. Delirium is often caused by underlying issues such as infections, medication side effects, or metabolic imbalances. Addressing these root causes can help resolve delirium more effectively. Administering antipsychotic or sedative medications should not be the initial approach as they can worsen delirium in some cases. Providing a low-stimulation environment is beneficial but not the priority when reversible causes need to be addressed first.
4. When providing discharge instructions for a client prescribed home oxygen, what is an essential safety measure?
- A. Ensure the client has cotton bedding
- B. Keep the oxygen equipment away from heat sources
- C. Use wool blankets to ensure warmth
- D. Allow the client to use electronic devices near the oxygen supply
Correct answer: B
Rationale: The correct answer is B: 'Keep the oxygen equipment away from heat sources.' Placing oxygen equipment near heat sources can lead to fire hazards due to the flammability of oxygen. Cotton bedding or wool blankets are not directly related to oxygen safety measures. Allowing electronic devices near the oxygen supply can increase the risk of fire due to potential sparks or heat generated.
5. What are the key interventions for managing pneumonia?
- A. Administer antibiotics and monitor oxygen levels
- B. Administer bronchodilators and encourage deep breathing
- C. Provide fluids and monitor for dehydration
- D. Administer oxygen and provide bed rest
Correct answer: A
Rationale: The correct answer is A: Administer antibiotics and monitor oxygen levels. Antibiotics are essential to treat the infection caused by bacteria in pneumonia, while monitoring oxygen levels helps ensure adequate oxygenation. Administering bronchodilators and encouraging deep breathing, as in choice B, are more commonly associated with managing conditions like asthma or COPD, not pneumonia. Providing fluids and monitoring for dehydration, as in choice C, are important for various conditions but not specific to pneumonia management. Administering oxygen and providing bed rest, as in choice D, may be supportive measures in pneumonia treatment, but the key intervention is administering antibiotics.
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