Nursing Elites

1. In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will:

• A. Be at an increased susceptibility for infection
• B. Have a wound that heals more slowly
• C. Experience more pain during the healing process
• D. Require more frequent dressing changes

Correct answer: A

Rationale: Wounds healing by secondary intention involve the gradual filling of the wound with granulation tissue, leading to a higher risk of infection due to prolonged exposure. This makes choice A the correct answer. Choices B and C are incorrect because wounds healing by secondary intention take longer to heal and often result in more pain compared to wounds healing by primary intention. Choice D is also incorrect as wounds healing by secondary intention usually require more frequent dressing changes to prevent infection and promote healing.

2. A nurse is preparing change of shift report after the night shift using one SBAR communication tool. Which of the following data should the nurse include when reporting background information?

• A. “Blood pressure 160/92 mm Hg”
• B. “Start the first dose of penicillin at 1200”
• C. “Pain rating of 5 on a scale from 0 to 10”
• D. “Code status: do-not-resuscitate”

Correct answer: B

Rationale: The correct answer is B. When providing background information in a shift report using the SBAR communication tool, the nurse should include details related to medication administration and orders. This helps ensure continuity of care and accurate handover of responsibilities. Choices A, C, and D do not typically fall under background information for shift reports. A blood pressure reading, pain rating, and code status are more relevant to the patient's current condition and status, rather than background information about medications or orders.

3. A client's readiness to learn about insulin administration is being assessed by a nurse. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

• A. ''I can concentrate best in the morning.''
• B. ''It is difficult to read the instructions because my glasses are at home.''
• C. ''I'm wondering why I need to learn this.''
• D. ''You will have to talk to my wife about this.''

Correct answer: A

Rationale: Choice A is the correct answer because the client's statement about the best time to concentrate indicates readiness for learning. This statement shows an awareness and interest in learning. Choice B is incorrect as it indicates a barrier to learning due to not having glasses. Choice C is incorrect as it shows a lack of understanding or motivation for learning. Choice D is incorrect as it suggests a lack of personal involvement or responsibility in the learning process since the client is deflecting the responsibility to someone else.

4. A healthcare professional is admitting a client who has influenza. Which of the following types of transmission precautions should the healthcare professional initiate?

• A. Airborne
• B. Droplet
• C. Contact
• D. Protective environment

Correct answer: B

Rationale: Droplet precautions should be initiated for clients with infections that spread via droplet nuclei larger than 5 microns in diameter, such as influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. In the case of influenza, the virus is primarily spread through respiratory droplets produced when an infected person coughs, sneezes, or talks. Airborne precautions are used for pathogens that remain infectious over long distances, typically smaller than 5 microns, like tuberculosis. Contact precautions are for diseases transmitted by direct or indirect contact, and protective environment precautions are for immunocompromised individuals to protect them from environmental pathogens.

5. A client has extracellular fluid volume deficit. Which of the following findings should the nurse expect?

• A. Postural hypotension
• B. Distended neck veins
• C. Dependent edema
• D. Bradycardia

Correct answer: A

Rationale: Postural hypotension is a common sign of extracellular fluid volume deficit due to decreased blood volume, leading to a drop in blood pressure upon standing. Distended neck veins, dependent edema, and bradycardia are not typically associated with extracellular fluid volume deficit. Distended neck veins are more indicative of fluid volume overload, dependent edema is a sign of fluid retention, and bradycardia is not a common finding in extracellular fluid volume deficit.

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