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. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?

• A. Ask the family to wait in the cafeteria while the next of kin makes the necessary arrangements
• B. Provide space and privacy for the family to share their concerns about the client’s discharge
• C. Ask the social worker to encourage the family to clear the hallway
• D. Explain to the family the client’s need for privacy so that she can make independent decisions

Correct answer: B

Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client’s discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.

3. The client is receiving discharge teaching for a new diagnosis of asthma. Which statement by the client indicates a need for further teaching?

• A. I should use my inhaler as soon as I begin to feel short of breath.
• B. I should avoid using my inhaler unless I am having an asthma attack.
• C. I should use my inhaler 30 minutes before exercise.
• D. I should rinse my mouth after using my inhaler.

Correct answer: B

Rationale: The statement 'I should avoid using my inhaler unless I am having an asthma attack' (B) indicates a need for further teaching. It is important for clients to use their inhaler as prescribed, which may include regular use to prevent asthma attacks. Choice A is correct because using the inhaler when feeling short of breath can help manage asthma symptoms. Choice C is also correct as using the inhaler before exercise can prevent exercise-induced symptoms. Choice D is correct as rinsing the mouth after using the inhaler helps prevent oral thrush, a potential side effect of inhaled corticosteroids. Therefore, option B is the most concerning statement that needs clarification.

4. A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?

• A. Hydrogel dressing.
• B. Exudate absorber.
• C. Wet-to-moist dressing.
• D. Transparent adhesive film.

Correct answer: C

Rationale: The best initial dressing for a stage four pressure ulcer with necrotic tissue is a wet-to-moist dressing. This dressing helps to provide moisture, soften necrotic tissue, and prepare the wound bed for healing. It promotes autolytic debridement and can help manage malodorous drainage. Once the necrotic tissue is loosened, other advanced dressings like hydrogel or alginate may be used in the wound bed to facilitate healing.

5. The client with cholecystitis is being instructed on dietary choices. Which meal best meets the dietary needs of this client?

• A. Steak, baked beans, and a salad
• B. Broiled fish, green beans, and an apple
• C. Pork chops, macaroni and cheese, and grapes
• D. Avocado salad, milk, and angel food cake

Correct answer: B

Rationale: Cholecystitis requires a low-fat diet to reduce stress on the gallbladder. The meal of broiled fish, green beans, and an apple aligns with this dietary recommendation by providing lean protein and low-fat, high-fiber foods that are easier for the body to digest, making it the most suitable choice for a client with cholecystitis.

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