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. The client is reviewing the signed operative consent with a nurse, who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement?

• A. Notify the surgical team of the client’s confusion
• B. Have the client sign a new surgical consent
• C. Add the correct leg information to the consent form
• D. Inform the surgeon about the client’s concern

Correct answer: D

Rationale: In this scenario, the nurse should inform the surgeon about the client’s concern immediately. This is important to ensure that the correct procedure is performed on the intended leg. Communication with the surgeon is crucial to address any discrepancies in the consent form and prevent errors during the surgical procedure. Having the surgeon clarify and correct the consent form is essential to maintain patient safety and uphold the principles of informed consent.

3. Which instruction should be included in the discharge teaching plan for an adult client with hypernatremia?

• A. Monitor daily urine output volume
• B. Drink plenty of water whenever thirsty
• C. Use salt tablets for sodium content
• D. Review food labels for sodium content

Correct answer: D

Rationale: In hypernatremia, there is an excess of sodium in the blood. Reviewing food labels for sodium content is crucial as it helps the client identify and avoid high-sodium foods, which can contribute to elevated sodium levels. Monitoring urine output volume may be important for other conditions but is not directly related to managing hypernatremia. Drinking water whenever thirsty is generally good advice for staying hydrated but does not specifically address the issue of high sodium levels. Using salt tablets would worsen hypernatremia by further increasing sodium intake.

4. A client is receiving external radiation therapy for lung cancer. Which intervention is most important for the nurse to include in the client's plan of care?

• A. Encourage the client to use sunscreen when outdoors.
• B. Apply a heating pad to the radiation site.
• C. Instruct the client to avoid using deodorant on the skin near the radiation site.
• D. Advise the client to increase intake of green leafy vegetables.

Correct answer: C

Rationale: Instructing the client to avoid using deodorant on the skin near the radiation site (C) is crucial to prevent skin irritation and potential adverse reactions during external radiation therapy. Sunscreen (A), heating pad (B), and dietary changes (D) are less pertinent in this situation.

5. The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?

• A. Use an electronic sphygmomanometer to take the BP every 30 minutes.
• B. Retake the blood pressure in the same arm, deflating the cuff slowly.
• C. Ask another healthcare provider to recheck the blood pressure to compare results.
• D. Obtain another blood pressure cuff and retake the blood pressure.

Correct answer: B

Rationale: The healthcare provider should first retake the blood pressure in the right arm, deflating the cuff slowly, because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. Taking the BP in the same arm ensures consistency and accuracy of the measurement.

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