Nursing Elites

1. What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?

• A. Apply hydrocolloid dressing
• B. Provide wound debridement
• C. Change the dressing daily
• D. Elevate the affected area

Correct answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.

2. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea. Which of the following actions should the nurse take?

• A. Encourage the client to take deep breaths.
• B. Place the client in a high-Fowler's position.
• C. Administer a bronchodilator.
• D. Administer oxygen at 6 L/min via face mask.

Correct answer: B

Rationale: The correct answer is to place the client in a high-Fowler's position. This position helps improve breathing by expanding the lungs and aiding in better oxygenation. Encouraging the client to take deep breaths may not be effective in managing dyspnea in COPD as it can lead to fatigue. Administering a bronchodilator may be necessary but placing the client in a high-Fowler's position should be the priority. Administering oxygen at 6 L/min via face mask may also be needed, but positioning is the initial intervention to optimize respiratory function.

3. A client is receiving furosemide for heart failure. Which of the following findings should the nurse report to the provider?

• A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
• B. Heart rate of 68/min.
• C. Potassium level of 3.8 mEq/L.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: The correct answer is B. A heart rate of 68/min is lower than expected and should be reported as it may indicate digoxin toxicity. Choices A, C, and D are within normal limits for a client receiving furosemide for heart failure and do not require immediate reporting. Weight loss may be expected due to diuretic therapy, a potassium level of 3.8 mEq/L is within the normal range, and a urine output of 60 mL/hr indicates adequate renal perfusion.

4. A nurse is teaching a prenatal class about infections. Which statement by a participant indicates a need for further teaching?

• A. I can clean the cat's litter box during pregnancy.
• B. I can visit someone with the flu after receiving the vaccine.
• C. I should take antibiotics for viral infections.
• D. I should wash my hands after gardening.

Correct answer: C

Rationale: The correct answer is C. This statement indicates a need for further teaching because antibiotics are ineffective against viral infections. It is important to educate the participant that antibiotics are only effective against bacterial infections, not viral ones. Choices A, B, and D are correct statements that promote good hygiene practices and infection prevention during pregnancy.

5. A healthcare professional is reviewing laboratory results for a client who has cirrhosis. Which of the following findings should the professional report to the provider?

• A. Albumin 3.5 g/dL
• B. Bilirubin 1.0 mg/dL
• C. INR 3.0
• D. Ammonia 80 mcg/dL

Correct answer: C

Rationale: An INR of 3.0 is elevated, indicating impaired blood clotting function, which poses a significant risk of bleeding in clients with cirrhosis. This finding should be promptly reported to the provider for further evaluation and management. Choice A (Albumin 3.5 g/dL) is within the normal range and indicates adequate liver synthetic function, so it does not require immediate reporting. Choice B (Bilirubin 1.0 mg/dL) is also within the normal range and typically seen in clients without significant liver dysfunction, so it does not need urgent attention. Choice D (Ammonia 80 mcg/dL) is elevated, but it is not the priority finding in cirrhosis; elevated ammonia levels are associated with hepatic encephalopathy rather than increased bleeding risk.

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