Nursing Elites

1. When providing care for an unconscious client who has seizures, which nursing intervention is most essential?

• A. Ensure oral suction is available.
• B. Maintain the client in a semi-Fowler's position.
• C. Provide frequent mouth care.
• D. Keep the room at a comfortable temperature.

Correct answer: A

Rationale: During seizures in an unconscious client, ensuring oral suction is available is crucial to managing secretions and preventing aspiration. This intervention helps maintain a clear airway and reduce the risk of complications. Maintaining the client in a semi-Fowler's position (Choice B) may be important for airway management but is not as critical as having oral suction ready. Providing frequent mouth care (Choice C) and keeping the room at a comfortable temperature (Choice D) are important aspects of overall care but are not as urgently needed as ensuring oral suction for managing secretions during seizures.

2. A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern?

• A. Albumin level of 2.5 g/dL
• B. Phosphorus level of 5 mg/dL
• C. Sodium level of 135 mmol/L
• D. Potassium level of 5.5 mmol/L

Correct answer: A

Rationale: In chronic renal failure, a protein-restricted diet is crucial to prevent the buildup of waste products. A low albumin level (<3.5 g/dL) indicates inadequate protein intake, raising concern as it may lead to malnutrition and tissue breakdown. Phosphorus, sodium, and potassium levels are not directly impacted by protein intake. Phosphorus levels may elevate in renal failure, but at 5 mg/dL, it is within normal range. Sodium and potassium levels are also within normal limits and not influenced by protein restriction.

3. An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.

• A. Apply lanolin or petroleum jelly to intact skin.
• B. Follow a reduced-calorie, reduced-fat diet.
• C. Inspect the involved areas daily for new ulcerations.
• D. Instruct the client to limit activities of daily living (ADLs).

Correct answer: A

Rationale: To address dry skin and prevent chronic ulcers and infections in an overweight client on warfarin with decreased arterial blood flow, the nurse should instruct the client to apply lanolin or petroleum jelly to intact skin. This helps maintain skin integrity and moisture. Following a reduced-calorie, reduced-fat diet (Choice B) may be beneficial for weight management but is not directly related to skin care. Inspecting involved areas daily for new ulcerations (Choice C) is important for skin assessment and early intervention but does not specifically address dry skin. Instructing the client to limit activities of daily living (ADLs) (Choice D) is not necessary for addressing dry skin; in fact, promoting mobility and circulation through appropriate activities is crucial.

4. The healthcare professional assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory results should the healthcare professional review?

• A. Red blood cell count
• B. Platelet count
• C. Hemoglobin levels
• D. White blood cell count

Correct answer: B

Rationale: The platelet count is the most appropriate laboratory result to review in a client presenting with petechiae and ecchymosis. Petechiae and ecchymosis are indicative of potential bleeding issues, which can be caused by low platelet count or impaired platelet function. Platelets are essential for clotting, and a low platelet count can lead to bleeding disorders. Reviewing the platelet count will provide valuable information about the client's clotting ability. Choice A, red blood cell count, is not typically associated with petechiae and ecchymosis. Hemoglobin levels (Choice C) are more related to anemia than bleeding disorders like thrombocytopenia. White blood cell count (Choice D) is not directly linked to the presence of petechiae and ecchymosis, which are more specific to platelet-related issues.

5. A client's laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which assessment finding is most often associated with hyperthyroidism?

• A. Periorbital edema.
• B. Atrophied thyroid gland.
• C. Increased pulse rate.
• D. Diarrhea stools.

Correct answer: C

Rationale: Increased pulse rate is commonly associated with hyperthyroidism due to the increased metabolic rate. Periorbital edema (Choice A) is more commonly associated with conditions like nephrotic syndrome or heart failure, not hyperthyroidism. Atrophied thyroid gland (Choice B) is not typically an assessment finding for hyperthyroidism as the gland is usually enlarged in this condition. Diarrhea stools (Choice D) can occur in hyperthyroidism, but it is not the most common assessment finding associated with the condition.

Similar Questions