Nursing Elites

1. Which client is at highest risk for developing a pressure ulcer?

• A. 23 year-old in traction for fractured femur
• B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
• C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
• D. 30 year-old who is comatose following a ruptured aneurysm

Correct answer: C

Rationale: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

2. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

• A. Altered tissue perfusion
• B. Risk for fluid volume deficit
• C. High risk for hemorrhage
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'Risk for infection.' When the membranes are ruptured for more than 24 hours prior to birth, there is a significantly increased risk of infection for both the mother and the newborn. Monitoring for signs of infection, such as fever, foul-smelling vaginal discharge, and uterine tenderness, is crucial. Option A, 'Altered tissue perfusion,' is not the priority in this scenario as infection risk takes precedence due to the prolonged rupture of membranes. Option B, 'Risk for fluid volume deficit,' is less of a priority compared to the immediate risk of infection. Option C, 'High risk for hemorrhage,' is not the priority concern at this time based on the information provided.

3. A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?

• A. Heparin will dissolve clots that you have.
• B. Heparin will reduce the platelets that make your blood clot.
• C. Heparin will work better than warfarin.
• D. Heparin will prevent new clots from developing.

Correct answer: D

Rationale: The correct answer is D: 'Heparin will prevent new clots from developing.' Heparin is an anticoagulant medication that helps prevent the formation of new blood clots. It does not dissolve existing clots (choice A), reduce platelets (choice B), or necessarily work 'better' than warfarin (choice C) but rather functions differently. The primary action of heparin is to prevent the development of new clots, especially in conditions where clot formation is a concern.

4. The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?

• A. We will encourage our child to cough every few hours on a daily basis.
• B. We will make sure that our child participates in physical activity every day.
• C. We will provide comfort measures to reduce any crying periods by our child.
• D. We will be sure to give our child a Fleet enema every day to prevent constipation.

Correct answer: C

Rationale: The correct answer is providing comfort measures to reduce any crying periods by the child. This can include offering a warm bath, avoiding upright positioning, and using other comfort measures to reduce crying, which can help reduce a hernia. Encouraging coughing or physical activity can increase strain on the hernia. Giving a Fleet enema daily for constipation is not recommended as it can also increase strain on the hernia.

5. When reading a lab report, you notice that a patient's sample is described as having anisocytosis. Which of the following most accurately describes the patient's condition?

• A. The patient has an abnormal condition of skin cells.
• B. The patient's red blood cells vary in size.
• C. The patient has a high level of fat cells and is obese.
• D. The patient's cells are indicative of necrosis.

Correct answer: B

Rationale: Anisocytosis is a term that indicates variation in the size of red blood cells. When a patient is described as having anisocytosis, it means their red blood cells exhibit differences in size. This condition can be detected in blood samples and may indicate underlying blood disorders. The other choices are incorrect: Choice A refers to a skin cell condition, Choice C relates to obesity and fat cells, and Choice D suggests necrosis, none of which are associated with anisocytosis or red blood cell abnormalities. It is important to recognize specific terms like anisocytosis in laboratory reports to understand the potential implications for the patient's health.

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