Nursing Elites

1. An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom?

• A. Leukocytosis and febrile.
• B. Polycythemia and crackles.
• C. Pharyngitis and sputum production.
• D. Confusion and tachycardia.

Correct answer: D

Rationale: The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch.

2. An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client’s laboratory work that the client’s hematocrit is normal?

• A. 10%
• B. 22%
• C. 30%
• D. 43%

Correct answer: D

Rationale: The normal hematocrit for an adult female client ranges from 35% to 47%. A hematocrit value of 43% falls within this normal range, indicating normal levels of red blood cells. Choices A, B, and C are low hematocrit values and are considered below the normal range for adult females, signifying potential anemia or other health issues.

3. A young female client prescribed amoxicillin (Amoxil) for a urinary tract infection is being taught by a nurse. Which statement should the nurse include in this client’s teaching?

• A. Use a second form of birth control while taking this medication.
• B. You will experience increased menstrual bleeding while on this medication.
• C. You may experience an irregular heartbeat while on this medication.
• D. Watch for blood in your urine while taking this drug.

Correct answer: A

Rationale: The correct statement for the nurse to include in the teaching is to advise the client to use a second form of birth control while taking amoxicillin. Penicillin, like amoxicillin, may reduce the effectiveness of estrogen-containing contraceptives, making it important to use additional contraceptive measures. The incorrect choices are B, C, and D. Increased menstrual bleeding, irregular heartbeat, or blood in the urine are not common side effects associated with amoxicillin use for a urinary tract infection.

4. A client recovering from surgery has a large abdominal wound. Which of the following foods, high in vitamin C, should the nurse encourage the client to eat to promote wound healing?

• A. Steak
• B. Veal
• C. Cheese
• D. Oranges

Correct answer: D

Rationale: Oranges are a rich source of vitamin C, which is essential for wound healing due to its role in collagen synthesis. Citrus fruits like oranges, as well as other fruits and vegetables such as strawberries, kiwi, bell peppers, and broccoli, are high in vitamin C. Meats like steak and veal are not significant sources of vitamin C; they are primarily sources of protein. Cheese is not a good source of vitamin C but does provide calcium and protein.

5. In the change-of-shift report, the nurse is told that a client has a Stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?

• A. Shallow open ulcer with a red-pink wound bed.
• B. A deep pocket of infection and necrotic tissues.
• C. An area of erythema that is painful to touch.
• D. Visible subcutaneous tissue with sloughing.

Correct answer: A

Rationale: A Stage 2 pressure ulcer typically presents as a shallow open ulcer with a red-pink wound bed. This appearance is characteristic of a Stage 2 pressure ulcer where there is partial thickness skin loss involving the epidermis and possibly the dermis. Choice B, a deep pocket of infection and necrotic tissues, is more indicative of a Stage 3 or Stage 4 pressure ulcer where the ulcer extends into deeper tissue layers. Choice C, an area of erythema that is painful to touch, is more commonly seen in early-stage pressure ulcers such as Stage 1. Choice D, visible subcutaneous tissue with sloughing, is characteristic of a more severe stage of pressure ulcer beyond Stage 2.

Similar Questions