Nursing Elites

1. 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.

2. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?

• A. Decrease intake of fluids after the evening meal.
• B. Drink a glass of cranberry juice every day.
• C. Drink a glass of warm decaffeinated beverage at bedtime.
• D. Consult the healthcare provider about a sleeping pill.

Correct answer: A

Rationale: The correct instruction for the nurse to provide is to advise the client to decrease intake of fluids after the evening meal. By reducing fluid intake before bedtime, the client can minimize the need to void during the night, which can help improve sleep patterns affected by nocturia. Choices B, C, and D are incorrect. Drinking cranberry juice or warm decaffeinated beverage at bedtime may increase fluid intake, exacerbating the nocturia issue. Consulting the healthcare provider about a sleeping pill should not be the first intervention, as it is important to try non-pharmacological approaches first.

3. A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?

• A. The client's respiratory rate is 14 breaths per minute.
• B. The client's oxygen saturation is 92%.
• C. The client reports shortness of breath.
• D. The client's respiratory rate is 24 breaths per minute.

Correct answer: C

Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A) is within an acceptable range for a client with COPD and does not require immediate action. An oxygen saturation of 92% (B) is slightly lower but still acceptable in COPD patients. Although a respiratory rate of 24 (D) is higher, it is not as immediately concerning as shortness of breath in this context.

4. A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?

• A. Epigastric pain that radiates to the back.
• B. Abdominal pain with guarding.
• C. Nausea and vomiting.
• D. Increased bowel sounds in all quadrants.

Correct answer: A

Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. While abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis, they are less specific and may be seen in various other gastrointestinal conditions. Therefore, the most indicative finding for acute pancreatitis is epigastric pain that radiates to the back.

5. How many drops per minute should a client weighing 182 pounds receive if a nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min? The drip factor is 60 gtt/ml.

• A. 31 gtt/min.
• B. 62 gtt/min.
• C. 93 gtt/min.
• D. 124 gtt/min.

Correct answer: D

Rationale: To determine the drops per minute for the client, first convert the client's weight from pounds to kilograms: 182/2.2 = 82.73 kg. Calculate the dosage by multiplying 5 mcg by the client's weight in kg: 5 mcg/kg/min × 82.73 kg = 413.65 mcg/min. Find the concentration of the solution in mcg/ml by dividing 250 ml by 50,000 mcg (50 mg): 250 ml/50,000 mcg = 200 mcg/ml. As the client needs 413.65 mcg/min and the solution is 200 mcg/ml, the client should receive 2.07 ml per minute. Finally, using the drip factor of 60 gtt/ml, multiply the ml per minute by the drip factor: 60 gtt/ml × 2.07 ml/min = 124.28 gtt/min, which rounds to 124 gtt/min. Therefore, the client should receive 124 drops per minute. Choice D is the correct answer. Choices A, B, and C are incorrect because they do not reflect the accurate calculation based on the client's weight, dosage, concentration of the solution, and drip factor.

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