Nursing Elites

1. The nurse is preparing a client for surgery. What action is most important for the nurse to take?

• A. Ensure that the client signs the consent form.
• B. Review the client's allergies with the surgical team.
• C. Confirm the client's identity using two identifiers.
• D. Verify that the surgical site is marked.

Correct answer: A

Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.

2. What assessment finding places a client at risk for problems associated with impaired skin integrity?

• A. Scattered macules on the face
• B. Capillary refill of 5 seconds
• C. Smooth nail texture
• D. Presence of skin tenting

Correct answer: B

Rationale: The correct answer is B. A capillary refill time greater than 3 seconds indicates poor perfusion, leading to impaired skin integrity. Delayed capillary refill can compromise blood flow to the skin, increasing the risk of pressure ulcers or wounds due to reduced tissue perfusion. Choices A, C, and D are incorrect because scattered macules on the face, smooth nail texture, and presence of skin tenting are not direct indicators of impaired skin integrity or risk for skin problems.

3. When faced with caring for a close friend in a professional setting, which action should the staff member take first?

• A. Notify the friend that all medical information will be kept confidential.
• B. Explain the relationship to the charge nurse and ask for reassignment.
• C. Approach the client and ask if the assignment is uncomfortable.
• D. Accept the assignment but protect the client's confidentiality.

Correct answer: B

Rationale: When faced with caring for a close friend in a professional setting, the staff member should first explain the relationship to the charge nurse and ask for reassignment. This is important to maintain professional boundaries, prevent conflicts of interest, and ensure that the care provided is unbiased and without compromising the friend's confidentiality. Choice A is incorrect because the priority should be on professional boundaries rather than informing the friend about confidentiality. Choice C is not appropriate as it puts the burden on the client to address any discomfort. Choice D is incorrect as accepting the assignment without addressing the potential conflict of interest could lead to compromised care.

4. The healthcare professional is assessing a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most indicative of this condition?

• A. Dependent rubor.
• B. Absence of hair on the lower legs.
• C. Shiny, thin skin on the legs.
• D. Pain in the legs when walking.

Correct answer: D

Rationale: Pain in the legs when walking (D), known as intermittent claudication, is most indicative of peripheral arterial disease (PAD). While dependent rubor (A), absence of hair (B), and shiny, thin skin (C) are also associated with PAD, they are less specific than intermittent claudication. Intermittent claudication is a hallmark symptom of PAD caused by inadequate blood flow to the legs during exercise, resulting in pain that resolves with rest.

5. A client with a diagnosis of hyperkalemia is receiving sodium polystyrene sulfonate (Kayexalate). Which laboratory value should the nurse monitor to evaluate the effectiveness of this medication?

• A. Serum sodium level.
• B. Serum potassium level.
• C. Serum calcium level.
• D. Serum glucose level.

Correct answer: B

Rationale: The correct answer is B: Serum potassium level. Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, leading to potassium removal from the body. Monitoring the serum potassium level allows the nurse to assess the effectiveness of this medication in lowering the elevated potassium levels. Serum sodium (A), calcium (C), and glucose (D) levels are not directly impacted by the action of sodium polystyrene sulfonate.

Similar Questions