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 reviewing the medical record of a client who is taking furosemide. Which of the following findings should the nurse report to the provider?

• A. Potassium level of 3.8 mEq/L
• B. Sodium level of 135 mEq/L
• C. Magnesium level of 1.6 mEq/L
• D. Calcium level of 8.5 mg/dL

Correct answer: C

Rationale: The correct answer is C. A magnesium level of 1.6 mEq/L is within the normal range, but monitoring potassium levels is crucial for clients taking furosemide. Furosemide can cause hypokalemia (low potassium levels), which can lead to adverse effects such as cardiac dysrhythmias. Sodium and calcium levels are not typically affected by furosemide, so they are not the priority findings to report to the provider in this case.

3. A client is reinforcing teaching with a nurse about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client exhales deeply before inhaling
• B. The client attempts to elevate the cylinder by inhaling deeply
• C. The client inhales quickly through the spirometer
• D. The client inhales several short breaths

Correct answer: B

Rationale: The correct answer is B because inhaling deeply and slowly elevates the cylinder on the spirometer, promoting lung expansion. Choice A is incorrect as exhaling deeply before inhaling is not the correct technique for using an incentive spirometer. Choice C is incorrect as inhaling quickly through the spirometer does not promote optimal lung expansion. Choice D is incorrect as inhaling several short breaths does not facilitate the proper use of an incentive spirometer.

4. A nurse is providing discharge instructions to a client with oxygen therapy. What should the nurse emphasize?

• A. Avoid keeping oxygen tanks in an upright position
• B. Keep oxygen equipment at least 6 feet away from heat sources
• C. Allow family members to smoke in designated areas
• D. Restrict fluid intake while using oxygen therapy

Correct answer: B

Rationale: The correct answer is B: 'Keep oxygen equipment at least 6 feet away from heat sources.' It is crucial to keep oxygen equipment away from heat sources to prevent fire hazards. Option A is incorrect as oxygen tanks should be stored in an upright position. Option C is wrong because smoking near oxygen equipment poses a significant fire risk. Option D is also incorrect as fluid intake should not be restricted while using oxygen therapy; in fact, it is important to maintain adequate hydration.

5. Which type of infectious diseases are required to be reported to the health department?

• A. Staphylococcus aureus infections, including MRSA
• B. Severe cases of flu-like symptoms
• C. Common colds and non-severe respiratory infections
• D. Only contagious diseases like meningitis

Correct answer: A

Rationale: The correct answer is A: Staphylococcus aureus infections, including MRSA. Severe infections like MRSA are required to be reported to the health department as they pose a significant public health risk. Choices B, C, and D are incorrect because severe flu-like symptoms, common colds, and non-severe respiratory infections, and only contagious diseases like meningitis do not fall under the category of infectious diseases that must be reported to the health department.

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