Nokea
An elderly client is admitted to a skilled nursing care facility. When doing a skin assessment, the nurse notes a 3-cm round area of partial-thickness skin loss that looks like a blister on the client's sacrum. The nurse interprets this to be a:
- A. stage I pressure ulcer.
- B. stage II pressure ulcer.
- C. stage III pressure ulcer.
- D. stage IV pressure ulcer.
Correct Answer: B
Rationale: A stage II pressure ulcer involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer, matching the description. Stage I is non-blanchable erythema, stage III involves full-thickness loss, and stage IV extends to muscle/bone.
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A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting.
- A. What is the best indication that the nutritional status of a woman with metastatic ovarian cancer has improved after 4 days of TPN?
- B. The patient eats most of the food served to her.
- C. The patient has gained 1 pound since admission.
- D. The patient’s albumin level is 0 mg/dL.
- E. The patient’s hemoglobin is 8.5 g/dL.
Correct Answer: C
Rationale: Albumin levels (normal 5–5.0 g/dL) are the best indicator of long-term nutritional status, reflecting protein stores. A level of 0 mg/dL indicates improved nutrition. Eating more, weight gain (which may be fluid), or hemoglobin levels (affected by cancer or chemotherapy) are less reliable indicators.
A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)?
- A. Ask the client the degree of relief and document the client's response
- B. Decrease the set rate on the pump by 2 ml/minute
- C. Check the IV site for drainage and loose tape
- D. Assist the client with ambulation and a gown change with supervision
Correct Answer: D
Rationale: When directing the UAP, communicate clearly and specifically what the task is and what should be reported to the nurse. Implementation of routine tasks should be delegated since they do not require independent judgment.
A 3 year-old had a hip spica cast applied two hours ago. In order to facilitate drying, the nurse should
- A. Expose the cast to air and turn the child frequently
- B. Use a heat lamp to reduce the drying time
- C. Handle the cast with the abductor bar
- D. Turn the child as little as possible
Correct Answer: A
Rationale: Expose the cast to air and turn the child frequently. The child should be turned every two hours, with the cast's surface exposed to the air.
The nurse is teaching a client with a new diagnosis of depression about fluoxetine (Prozac). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report any suicidal thoughts.
- C. Stop the medication if mood improves.
- D. Avoid regular mental health follow-ups.
Correct Answer: B
Rationale: Suicidal thoughts are a serious fluoxetine side effect, requiring immediate reporting. Options A, C, and D are incorrect.
An adult male had a myocardial infarction six weeks ago. He asks the nurse if it is safe for him to have sex. What should the nurse include when replying?
- A. Taking nitroglycerin before sexual activity is often helpful.
- B. Taking drugs for erectile dysfunction in addition to nitroglycerin is advised.
- C. The client should rest for several hours before engaging in sexual activity.
- D. Sexual activity should be avoided for six months after a heart attack.
Correct Answer: A
Rationale: Nitroglycerin before sexual activity can prevent angina, and sexual activity is generally safe 6 weeks post-MI if the patient is stable.