Nursing Elites

1. A group of newly licensed nurses is being taught about the Braden Scale by a nurse. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

• A. “The client’s age is not a factor in the measurement.”
• B. “The scale measures six elements.”
• C. “A lower score indicates a higher risk of pressure ulcers.”
• D. “Each element is scored on a range from 1 to 4 points.”

Correct answer: B

Rationale: Choice B is the correct answer because the Braden Scale measures six elements: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction, and Shear. The other choices are incorrect because: Choice A states that the client's age is not a factor in the measurement, which is accurate as age is not included in the Braden Scale. Choice C incorrectly states that a lower score indicates a higher risk of pressure ulcers, which is the opposite of how the Braden Scale works. Choice D inaccurately describes the scoring range of each element on the Braden Scale, which is not from 1 to 4 points but rather from 1 to 3.

2. A client is being treated for diabetic ketoacidosis (DKA). Which laboratory value would be most concerning?

• A. Blood glucose of 350 mg/dL
• B. Serum bicarbonate of 18 mEq/L
• C. Arterial pH of 7.20
• D. Serum potassium of 5.5 mEq/L

Correct answer: C

Rationale: In a client with diabetic ketoacidosis (DKA), the most concerning laboratory value is an arterial pH of 7.20. An arterial pH of 7.20 indicates severe acidosis, which is a critical condition requiring immediate intervention. This pH level reflects a significant imbalance in the body's acid-base status, potentially leading to serious complications. High blood glucose levels (choice A) are expected in DKA but do not directly indicate the severity of acidosis. A serum bicarbonate level of 18 mEq/L (choice B) is low but not as immediately critical as a pH of 7.20. Serum potassium of 5.5 mEq/L (choice D) is elevated, which can occur in DKA due to insulin deficiency, but it is not the most concerning value in this scenario.

3. A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include?

• A. Carbon monoxide does not have a distinct odor.
• B. Water heaters should be inspected every 5 years.
• C. The lungs are not damaged from carbon monoxide inhalation.
• D. Carbon monoxide binds with hemoglobin in the body.

Correct answer: D

Rationale: The correct answer is D: 'Carbon monoxide binds with hemoglobin in the body.' Carbon monoxide is an odorless, colorless gas, so it does not have a distinct odor (Choice A). While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning (Choice B). Carbon monoxide primarily affects the cardiovascular system by binding with hemoglobin, reducing the blood's ability to carry oxygen, rather than causing direct lung damage (Choice C). Understanding how carbon monoxide binds with hemoglobin is crucial in recognizing the mechanism of poisoning and its potential consequences.

4. When administering otic ear medication to an adult client, what action should be done to ensure the medication reaches the inner ear?

• A. Press gently on the tragus of the client’s ear.
• B. Pull the ear lobe up and back.
• C. Insert the medication deeply into the ear canal.
• D. Massage the ear gently after administering the medication.

Correct answer: A

Rationale: The correct action to ensure the medication reaches the inner ear is to press gently on the tragus of the client’s ear. The tragus is the small pointed eminence of the external ear, and pressing on it helps direct the medication deeper into the ear canal. Pulling the ear lobe up and back (Choice B) is the correct technique for administering eardrops to a child, not an adult. Inserting the medication deeply into the ear canal (Choice C) can cause injury or discomfort as the eardrops are designed to flow into the ear canal naturally. Massaging the ear gently after administering the medication (Choice D) is unnecessary and may not help the medication reach the inner ear effectively.

5. A healthcare professional is teaching about home safety with a client. Which of the following instructions should the healthcare professional include?

• A. Unplug electronics by holding the plug
• B. Use electrical tape to secure extension cords next to baseboards on the floor
• C. To use a fire extinguisher, aim at the base of the flames
• D. Install slip-resistant rugs on tile floors

Correct answer: B

Rationale: The correct answer is to use electrical tape to secure extension cords next to baseboards on the floor. This practice helps prevent tripping and electrical hazards by keeping cords out of the way. Option A is incorrect as unplugging electronics should be done by holding the plug, not the cord itself. Option C is incorrect because when using a fire extinguisher, it should be aimed at the base of the flames, not at the top. Option D is not directly related to home safety teaching and may not be necessary for all clients, as it suggests an unnecessary change that may not improve safety.

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