Nursing Elites

1. 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.

2. The client with diabetes mellitus is being taught how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.)

• A. I can continue to take an aspirin every 4 to 8 hours for my pain.
• B. My weight should be maintained at a body mass index of 30.
• C. Smoking should be stopped as soon as possible.
• D. A & B

Correct answer: D

Rationale: The correct answer is D. Both statements A and B indicate a lack of understanding of CKD prevention. Taking aspirin every 4 to 8 hours can lead to kidney damage, and maintaining a body mass index (BMI) of 30 is considered overweight, which can increase the risk of developing CKD. Statement C, on the other hand, correctly addresses smoking cessation, which is crucial in preventing CKD. Therefore, choices A and B are incorrect as they do not align with CKD prevention strategies, making option D the correct choice.

3. A client’s baseline vital signs are temperature 98°F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever to 103°F. Which of the following respiratory rates would the nurse anticipate as part of the body’s response to the change in client status?

• A. 12 breaths/min
• B. 16 breaths/min
• C. 18 breaths/min
• D. 22 breaths/min

Correct answer: D

Rationale: When a client experiences a fever, there is an increase in body temperature, leading to a higher metabolic rate and oxygen demand. As a result, the respiratory rate typically increases to meet the body's increased oxygen needs. Therefore, in response to the fever spike from 98°F to 103°F, the nurse would anticipate a higher respiratory rate. Choices A, B, and C are incorrect because a decrease in body temperature, not an increase as seen in fever, would lead to a decrease in respiratory rate to conserve energy and oxygen consumption.

4. A client has a long history of hypertension. Which category of medication would the nurse expect to be ordered to avoid chronic kidney disease (CKD)?

• A. Antibiotic
• B. Histamine blocker
• C. Bronchodilator
• D. Angiotensin-converting enzyme (ACE) inhibitor

Correct answer: D

Rationale: The correct answer is D, Angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. By blocking this conversion, ACE inhibitors promote vasodilation and improve perfusion to the kidneys. Additionally, ACE inhibitors block the breakdown of bradykinin and prostaglandin, further contributing to vasodilation. They also lead to increased renin and decreased aldosterone levels. These effects help in reducing blood pressure and protecting the kidneys in clients with hypertension. Antibiotics are used to fight infections, histamine blockers reduce inflammation, and bronchodilators widen the bronchi, none of which address the underlying processes involved in slowing the progression of chronic kidney disease (CKD) in hypertensive clients.

5. A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mg/dL. What question should the nurse ask first when taking this client’s history?

• A. Have you been taking any aspirin, ibuprofen, or naproxen recently?
• B. Do you have anyone in your family with renal failure?
• C. Have you had a diet that is low in protein recently?
• D. Has a relative had a kidney transplant lately?

Correct answer: A

Rationale: The correct question to ask the client first is about their recent intake of nephrotoxic medications like aspirin, ibuprofen, or naproxen. Elevated serum creatinine and BUN levels indicate possible renal issues, making it crucial to assess potential causes such as medication-induced nephrotoxicity. Inquiring about family history of renal failure or recent kidney transplants would not provide immediate insights into the client's current renal condition. While a diet low in protein could influence BUN levels, it is important to address medication history first due to the acute presentation in the emergency department.

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