Nursing Elites

1. When assessing for criteria that signify malnutrition risk, which element would most likely be included as part of the functional assessment data?

• A. severity of illness
• B. presence of pressure sores
• C. localized edema
• D. generalized weakness

Correct answer: D

Rationale: Generalized weakness is a key indicator of malnutrition and is often assessed as part of functional status, reflecting muscle wasting and reduced physical function. The other choices, such as severity of illness, presence of pressure sores, and localized edema, are important factors to consider in a clinical assessment but are not primarily indicative of malnutrition risk. Generalized weakness directly relates to the functional impact of malnutrition on physical performance.

2. Which of the following interventions should be considered the highest priority when caring for June, who has hemiparesis secondary to a stroke?

• A. Position June in an upright lateral position
• B. Perform range of motion exercises
• C. Apply antiembolic stockings
• D. Use hand rolls or pillows for support

Correct answer: C

Rationale: The correct answer is C, 'Apply antiembolic stockings'. In the case of a patient who has experienced a stroke and is suffering from hemiparesis, the highest priority intervention is to prevent further complications such as deep vein thrombosis (DVT), which can be life-threatening. Antiembolic stockings are used to increase venous blood flow velocity and reduce the risk of DVT. Choice 'A', positioning June in an upright lateral position, while important for overall care, is not the highest priority. Choice 'B', performing range of motion exercises, is an important part of recovery but not the immediate priority. Choice 'D', using hand rolls or pillows for support, is also a valuable intervention but does not address the most pressing risk of further complications.

3. What is the first step in decontamination?

• A. Immediately applying a chemical decontamination foam to the area of contamination
• B. Thoroughly washing and rinsing the patient with soap and water
• C. Immediately applying personal protective equipment
• D. Removing the patient's clothing and jewelry, then rinsing the patient with water

Correct answer: D

Rationale: The correct first step in decontamination is to remove the patient's clothing and jewelry to prevent further exposure and then rinse the patient with water. This helps to eliminate any contaminants on the patient's body. Choice A is incorrect because applying a chemical decontamination foam should come after removing clothing. Choice B is incorrect as washing and rinsing the patient should follow the removal of clothing. Choice C is incorrect as personal protective equipment should be worn by the individual performing the decontamination, not applied to the patient.

4. A nurse is reviewing the medication administration record for a client who is 2 days postoperative following abdominal surgery. The nurse should recognize that which of the following medications places the client at risk for wound dehiscence?

• A. Omeprazole
• B. Zolmitriptan
• C. Prednisone
• D. Verapamil

Correct answer: C

Rationale: Corrected Rationale: Prednisone is a corticosteroid that can impair wound healing and increase the risk of wound dehiscence. Omeprazole (Choice A) is a proton pump inhibitor used to reduce stomach acid production and does not directly impact wound healing. Zolmitriptan (Choice B) is a medication used to treat migraines and does not affect wound healing. Verapamil (Choice D) is a calcium channel blocker used to treat high blood pressure and certain heart conditions, and it does not pose a significant risk for wound dehiscence.

5. What are symptoms of uncontrolled type 1 diabetes?

• A. Depression, anxiety, and fatigue
• B. Increased thirst, urination, and hunger
• C. Weight gain, macrosomia, and food cravings
• D. Poor wound healing, blurred vision, and recurrent infections

Correct answer: B

Rationale: The correct answer is B: Increased thirst, urination, and hunger. Uncontrolled type 1 diabetes typically presents with classic symptoms including polydipsia (increased thirst), polyuria (frequent urination), and polyphagia (increased hunger). These symptoms are often accompanied by weight loss due to the body's inability to properly utilize glucose for energy. Choices A, C, and D are incorrect as they do not align with the typical symptoms of uncontrolled type 1 diabetes. Depression, anxiety, fatigue, weight gain, macrosomia, food cravings, poor wound healing, blurred vision, and recurrent infections are not primary symptoms associated with uncontrolled type 1 diabetes.

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