Nursing Elites

1. The client with chronic venous insufficiency is being taught about self-care measures. Which instruction should be included?

• A. Avoid wearing compression stockings
• B. Elevate legs above heart level when resting
• C. Apply heat packs to improve circulation
• D. Limit walking to prevent leg pain

Correct answer: B

Rationale: The correct instruction for a client with chronic venous insufficiency is to elevate their legs above heart level when resting. This position helps reduce venous pressure and edema, improving circulation. Avoiding compression stockings (choice A) is incorrect as they are beneficial in managing chronic venous insufficiency. Applying heat packs (choice C) is not recommended as heat can worsen edema. Limiting walking (choice D) is not advisable as regular, gentle exercise like walking can actually help improve circulation in patients with chronic venous insufficiency.

2. When speaking to young parents, the nurse states that lead poisoning is one of the most common preventable health problems affecting children. What condition occurs when the level of lead ingested exceeds the amount that can be absorbed by the bone?

• A. Malnutrition
• B. Anemia
• C. Bone pain
• D. Diarrhea

Correct answer: B

Rationale: The correct answer is B: Anemia. When the amount of lead ingested exceeds the amount that can be absorbed by the bone, it leads to anemia. Malnutrition (Choice A) is a state of inadequate nutrition, not directly related to lead poisoning. Bone pain (Choice C) is a symptom of lead poisoning due to its effects on bones but not directly related to lead ingestion exceeding absorption. Diarrhea (Choice D) is not a direct consequence of lead ingestion exceeding absorption by bones.

3. Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?

• A. Risk for infection related to thrombolysis.
• B. Risk for fluid volume deficit related to thrombolysis.
• C. Risk for impaired skin integrity related to thrombolysis.
• D. Risk for injury related to effects of thrombolysis.

Correct answer: D

Rationale: Thrombolytic therapy increases the risk of bleeding, not infection, fluid volume deficit, or impaired skin integrity. The most significant concern with thrombolytic therapy is the potential for bleeding complications, which can lead to various injuries. Therefore, 'Risk for injury related to effects of thrombolysis' is the most appropriate nursing diagnosis in this scenario. Choices A, B, and C are incorrect as they do not directly correlate with the primary risk associated with thrombolytic therapy.

4. A client with partial-thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?

• A. Apply a sterile dressing to the wound.
• B. Administer an analgesic.
• C. Encourage the client to drink fluids.
• D. Ensure the client's nutritional needs are met.

Correct answer: B

Rationale: Administering an analgesic before whirlpool therapy is the priority intervention in this scenario. Whirlpool therapy for debridement can be painful for the client with partial-thickness burns. Administering an analgesic before the procedure helps manage pain during the debridement process, ensuring the client's comfort. Applying a sterile dressing (Choice A) may be necessary after the whirlpool therapy but is not the immediate pre-transport intervention. Encouraging the client to drink fluids (Choice C) and ensuring nutritional needs are met (Choice D) are important aspects of care but are not specifically related to preparing the client for whirlpool therapy.

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. Intact skin with non-blanchable redness.
• C. Full-thickness tissue loss with visible fat.
• D. Full-thickness tissue loss with exposed bone, tendon, or muscle.

Correct answer: A

Rationale: The correct answer is A: 'Shallow open ulcer with a red-pink wound bed.' Stage 2 pressure ulcers involve partial-thickness skin loss and typically appear as shallow open ulcers with a red-pink wound bed. Choice B describes a stage 1 ulcer, where the skin is intact but shows non-blanchable redness. Choice C describes a stage 3 ulcer, with full-thickness tissue loss exposing fat. Choice D is characteristic of a stage 4 ulcer, where there is full-thickness tissue loss exposing bone, tendon, or muscle. Therefore, option A best fits the description of a stage 2 pressure ulcer.

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