Nursing Elites

1. Which of the following findings should the nurse anticipate in the medical record of a client with a pressure ulcer?

• A. Serum albumin level of 3 g/dL
• B. Braden scale score of 20
• C. Norton scale score of 18
• D. Hemoglobin level of 13 g/dL

Correct answer: A

Rationale: The correct answer is A: Serum albumin level of 3 g/dL. A serum albumin level of 3 g/dL indicates poor nutrition, which is commonly seen in clients with pressure ulcers. Choice B, a Braden scale score of 20, is incorrect because a higher Braden scale score indicates a lower risk of developing pressure ulcers. Choice C, a Norton scale score of 18, is incorrect as it is a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer. Choice D, a hemoglobin level of 13 g/dL, is unrelated to pressure ulcers and does not directly reflect the nutritional status associated with this condition.

2. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

• A. Increased speech
• B. Lack of sleep
• C. Agitation
• D. Poor concentration

Correct answer: B

Rationale: The correct answer is lack of sleep (choice B). In acute mania, lack of sleep can exacerbate symptoms, lead to exhaustion, and pose serious risks to the client's well-being. Addressing the client's sleep deprivation is a priority as it can impact their overall health and recovery. Increased speech (choice A) and agitation (choice C) are common in acute mania but do not pose immediate physical risks like lack of sleep. Poor concentration (choice D) is also a symptom of acute mania but addressing sleep deprivation takes precedence due to its severe consequences.

3. A client has an NG tube that needs irrigation every 8 hours. Which solution should be used to irrigate the tube to maintain fluid and electrolyte balance?

• A. Tap water
• B. Sterile water
• C. 0.9% sodium chloride
• D. 0.45% sodium chloride

Correct answer: C

Rationale: The correct answer is 0.9% sodium chloride. This solution is isotonic and helps maintain electrolyte balance during irrigation, preventing fluid and electrolyte imbalances. Tap water (choice A) may cause electrolyte imbalances due to its hypotonic nature. Sterile water (choice B) is hypotonic and can lead to electrolyte disturbances. 0.45% sodium chloride (choice D) is hypotonic and may also disrupt electrolyte balance when used for irrigation.

4. A client at 30 weeks of gestation reports constipation. Which of the following recommendations should the nurse make?

• A. Drink 1 liter of water per day.
• B. Take a laxative every morning.
• C. Increase your intake of refined grains.
• D. Walk for at least 30 minutes every day.

Correct answer: D

Rationale: The correct recommendation is to walk for at least 30 minutes every day. Walking stimulates intestinal motility, which can help relieve constipation during pregnancy. Option A is important for overall hydration but may not directly address constipation. Option B is not recommended without healthcare provider approval as some laxatives are contraindicated in pregnancy. Option C, increasing intake of refined grains, may exacerbate constipation due to lower fiber content.

5. What should a healthcare professional do when a client with anorexia nervosa insists on working out constantly?

• A. Allow the client to workout and continue their regimen
• B. Restrict the client's workout regimen to one hour a day
• C. Discuss the risks of over-exercising with the client
• D. Speak to the client privately to uncover the source of the obsession

Correct answer: D

Rationale: When dealing with a client with anorexia nervosa who insists on working out constantly, it is crucial to address the situation sensitively. Speaking to the client privately to uncover the source of the obsession is the most appropriate action. This approach allows the healthcare professional to understand the underlying reasons for the behavior and work towards a solution together. Choices A and B could potentially exacerbate the client's condition by either enabling the behavior or imposing restrictions without addressing the root cause. While choice C is important, simply discussing the risks may not address the client's compulsion to exercise excessively.

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