Nursing Elites

1. Which client is at the highest risk for developing pressure ulcers?

• A. A 50-year-old client with a fractured femur
• B. A 30-year-old client with diabetes mellitus
• C. A 65-year-old client with limited mobility
• D. A 70-year-old client with a history of stroke

Correct answer: C

Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body. Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.

2. A client with diabetes mellitus is admitted with hyperglycemia. What is the priority nursing action?

• A. Administer insulin as prescribed
• B. Encourage fluid intake
• C. Monitor blood glucose levels frequently
• D. Assess for signs of hypoglycemia

Correct answer: A

Rationale: Administering insulin is the priority nursing action for a client admitted with hyperglycemia due to diabetes mellitus. Insulin helps lower blood glucose levels and prevent further complications associated with hyperglycemia. Encouraging fluid intake is important but not the priority as insulin administration takes precedence to address the immediate hyperglycemic state. Monitoring blood glucose levels frequently is essential but comes after administering insulin to ensure the treatment's effectiveness. Assessing for signs of hypoglycemia is incorrect as the client is admitted with hyperglycemia, which requires raising blood glucose levels, not lowering them further.

3. A client presents to the emergency department with symptoms of a myocardial infarction. What should the nurse administer immediately under doctor's orders?

• A. Aspirin to prevent further blood clotting
• B. High-flow oxygen
• C. Intravenous fluids
• D. Nitroglycerin

Correct answer: A

Rationale: The correct answer is A: Aspirin to prevent further blood clotting. Administering aspirin is crucial in the immediate management of a myocardial infarction as it helps prevent further blood clot formation, which is a key component in the treatment and prevention of myocardial infarction. Oxygen therapy (Choice B) is often provided, but aspirin takes precedence due to its role in reducing clot formation. Intravenous fluids (Choice C) may be needed but are not the immediate priority in this situation. Nitroglycerin (Choice D) is commonly used for chest pain relief in myocardial infarction but is not the first medication to be administered in this scenario.

4. A healthcare provider is conducting a health education session about the prevention of type 2 diabetes. What lifestyle modification should be emphasized?

• A. Increasing physical activity
• B. Reducing dietary sugar intake
• C. Regular health screenings
• D. All of the above

Correct answer: D

Rationale: To effectively prevent type 2 diabetes, individuals should focus on a combination of lifestyle modifications. Increasing physical activity helps maintain a healthy weight and improves insulin sensitivity. Reducing dietary sugar intake can lower the risk of developing diabetes by managing blood sugar levels. Regular health screenings are crucial for early detection and timely intervention. Emphasizing all these modifications together provides a comprehensive approach to diabetes prevention. Choices A, B, and C are all important components of a healthy lifestyle that can contribute to reducing the risk of type 2 diabetes.

5. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed fluoxetine (Prozac). What is the most important teaching point?

• A. Take the medication with or without food.
• B. Report any increase in suicidal thoughts.
• C. Avoid foods high in tyramine.
• D. Expect improvement within 24 hours.

Correct answer: B

Rationale: The correct teaching point is to instruct the client to report any increase in suicidal thoughts. This is crucial because SSRIs like fluoxetine can initially increase suicidal ideation, especially at the beginning of treatment. Choice A is corrected to emphasize that fluoxetine can be taken with or without food. Choice C is unrelated as it pertains more to MAOIs than SSRIs like fluoxetine. Choice D is inaccurate as antidepressants like fluoxetine may take weeks to show significant improvement in symptoms, not within 24 hours.

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