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 teaching a client with hypertension about using a blood pressure monitor. Which of the following instructions should the nurse include?

• A. Take your blood pressure after eating
• B. Sit quietly for 5 minutes before taking your blood pressure
• C. Use a blood pressure cuff that is too small
• D. Take your blood pressure while standing

Correct answer: B

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before taking their blood pressure. This is important because sitting quietly helps stabilize the heart rate, leading to a more accurate reading. Choice A is incorrect because taking blood pressure after eating can affect the readings. Choice C is wrong because using a blood pressure cuff that is too small can provide inaccurate readings. Choice D is also incorrect as blood pressure should be taken in a seated position for accurate results.

3. Which of the following findings indicates a need for immediate attention in a client diagnosed with delirium?

• A. Confusion and disorientation that resolve with rest
• B. A blood pressure reading of 110/70
• C. Irritability and agitation that worsen throughout the day
• D. Mild confusion during the evening hours

Correct answer: C

Rationale: The correct answer is C: Irritability and agitation that worsen throughout the day. These symptoms are concerning in a client diagnosed with delirium as they may indicate an exacerbation of the condition or an underlying cause that requires immediate attention. Option A describes symptoms that resolve with rest, which may not be as urgent. Option B provides a normal blood pressure reading, which is not typically associated with immediate attention in delirium cases. Option D describes mild confusion during specific hours, which may not be as critical as worsening symptoms throughout the day.

4. A healthcare professional is reviewing the laboratory report of a client who is receiving filgrastim. Which of the following laboratory values should the healthcare professional monitor to determine the effectiveness of the treatment?

• A. WBC count.
• B. Serum potassium.
• C. Hemoglobin level.
• D. Serum creatinine.

Correct answer: A

Rationale: Filgrastim works by stimulating the production of white blood cells. Therefore, monitoring the white blood cell (WBC) count is essential to assess the effectiveness of the treatment. Choice B, serum potassium, is not directly affected by filgrastim therapy. Choice C, hemoglobin level, is important but not the primary indicator of filgrastim's effectiveness. Choice D, serum creatinine, is unrelated to the action of filgrastim and would not reflect its effectiveness.

5. What are key signs of a urinary tract infection (UTI) in older adults?

• A. Confusion and increased temperature
• B. Painful urination and frequent urination
• C. Dizziness and headache
• D. Back pain and fever

Correct answer: A

Rationale: The correct answer is A. In older adults, key signs of a UTI often include confusion and increased temperature. Confusion is a common symptom in the elderly when they have a UTI, and an increase in body temperature can indicate an infection. Choices B, C, and D are incorrect because while painful urination and frequent urination are common UTI symptoms in general, they may not be as prominent in older adults. Dizziness, headache, back pain, and fever can be associated with other conditions but are not typically key signs of a UTI in older adults.

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