Nursing Elites

1. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?

• A. Place the client in the wheelchair for four hours each day
• B. Pad the bony prominences
• C. Reposition every two hours
• D. Massage reddened bony prominence

Correct answer: C

Rationale: Repositioning every two hours is the most effective measure in preventing skin breakdown for a client with a CVA. This practice helps to relieve pressure on the skin, reducing the risk of pressure ulcers. Placing the client in a wheelchair for extended periods (Choice A) can increase pressure on specific areas, leading to skin breakdown. Padding bony prominences (Choice B) can provide some protection but may not address the root cause of pressure ulcers. Massaging reddened bony prominences (Choice D) can potentially worsen the condition by causing further damage to already compromised skin.

2. Which of these findings would the nurse most closely associate with anemia in a 10-month-old infant?

• A. Hemoglobin level of 12 g/dL
• B. Pale mucosa of the eyelids and lips
• C. Hypoactivity
• D. A heart rate between 140 to 160

Correct answer: B

Rationale: The correct answer is B. Pale mucosa of the eyelids and lips is a classic sign of anemia in infants, indicating a lack of sufficient red blood cells. This finding is due to decreased hemoglobin levels, which causes reduced oxygen delivery to tissues. Choices A, C, and D are less specific to anemia in infants. While a hemoglobin level of 12 g/dL may be within the normal range for a 10-month-old infant, the presence of pale mucosa is a more indicative sign of anemia.

3. A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client?

• A. It is a condition in which one or more tumors, called gastrinomas, form in the pancreas or in the upper part of the small intestine (duodenum).
• B. It is critical to promptly report any findings of peptic ulcers to your health care provider.
• C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors.
• D. The average age at diagnosis is 50 years, and peptic ulcers may occur in unusual areas of the stomach or intestine.

Correct answer: B

Rationale: Prompt reporting of peptic ulcers is crucial in managing Zollinger-Ellison syndrome to prevent complications and guide treatment. While choices A, C, and D provide relevant information about the condition and its treatment, the most important aspect in the client's care is the prompt reporting of peptic ulcers. This is because untreated peptic ulcers in Zollinger-Ellison syndrome can lead to serious complications such as gastrointestinal bleeding or perforation. Therefore, ensuring timely communication with the healthcare provider is essential for effective management of the condition.

4. The nurse is caring for a client with a history of peptic ulcer disease. Which of these findings would be most concerning to the nurse?

• A. A heart rate of 72 beats per minute
• B. A hemoglobin level of 12 g/dL
• C. The client reports black, tarry stools
• D. The client reports nausea and vomiting

Correct answer: C

Rationale: Black, tarry stools can indicate gastrointestinal bleeding, which is a serious complication of peptic ulcer disease. This finding suggests active bleeding in the gastrointestinal tract, requiring immediate attention. A normal heart rate of 72 beats per minute (choice A) is within the expected range. A hemoglobin level of 12 g/dL (choice B) is also within normal limits. Nausea and vomiting (choice D) are common symptoms associated with peptic ulcer disease but may not necessarily indicate active bleeding like black, tarry stools.

5. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is the appropriate action in this scenario. It helps assess the client's ability to swallow safely without the risk of aspiration. Adding a thickening agent to the fluids (Choice A) may be considered later if swallowing difficulties persist. Feeding the client only solid foods (Choice C) can increase the risk of aspiration in this case, and increasing the rate of intravenous fluids (Choice D) does not address the swallowing concern.

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