Nokea
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. BUN
- B. Potassium
- C. RBC count
- D. WBC count
Correct Answer: D
Rationale: Elevated WBC count, especially neutrophils, indicates infection response in a pressure ulcer.
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A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Identify the clients at greatest risk for development of pressure ulcers.
- B. Use a barrier cream when performing perineal care.
- C. Turn and position each client every 2 hr.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: A
Rationale: Identifying at-risk clients prioritizes preventive efforts for pressure ulcer management.
A nurse in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?
- A. History of poor wound healing
- B. Random blood glucose 126 mg/dL
- C. Report of decreased urinary output
- D. Clammy skin
Correct Answer: A
Rationale: Poor wound healing is a hyperglycemia sign due to impaired immune response.
A nurse is assisting with teaching a client who is on a low potassium diet. Which of the following instructions should the nurse include?
- A. Choose orange juice instead of apple juice.
- B. Replace sugar with molasses when baking.
- C. Eat granola for breakfast.
- D. Avoid using salt substitutes when cooking.
Correct Answer: D
Rationale: Salt substitutes contain potassium chloride, increasing potassium intake, which should be avoided.
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Dry mucous membranes
- C. Diaphoresis
- D. Polyuria
Correct Answer: C
Rationale: Diaphoresis (sweating) is a classic sign of hypoglycemia due to sympathetic nervous system activation, unlike fruity breath (hyperglycemia) or polyuria (hyperglycemia).
A nurse is collecting data from a client who has an inadequate dietary intake of fiber. Which of the following findings should the nurse expect?
- A. Constipation
- B. Memory loss
- C. Brittle hair
- D. Bleeding gums
Correct Answer: A
Rationale: Insufficient fiber causes constipation by reducing bowel movement frequency.