Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?
A. Hgb 18 g/dL (12 to 16 g/dl)
B. WBC 12.000/mm3 (5,000 to 10,000/mm3)
C. 25-Hydroxyvitamin D 92 ng/ml. (25 to 80 ng/mL)
D. Albumin 3.1 g/dL (3.5 to 5 g/dL)
Albumin is a protein that plays a crucial role in maintaining skin health. Low albumin levels (hypoalbuminemia) can lead to poor wound healing and skin vulnerability. Hemoglobin level, white cell count and 25-hydroxyvitamin have no direct role in skin breakdown.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
Albumin is a protein that plays a crucial role in maintaining skin health. Low albumin levels (hypoalbuminemia) can lead to poor wound healing and skin vulnerability.
Hemoglobin level, white cell count and 25-hydroxyvitamin have no direct role in skin breakdown.
Similar Questions
A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/40 mm Hg. Which of the following medications should the nurse administer?
A. Naloxone
Naloxone is a medication used as an opioid antagonist to reverse the effects of opioid overdose, including respiratory depression and hypotension. In this scenario, the client's symptoms suggest opioid-induced respiratory depression, making naloxone the appropriate choice to reverse the effects of morphine.
B. Protamine sulfate
Protamine sulfate is used to reverse the anticoagulant effects of heparin, not for treating opioid- induced respiratory depression and hypotension.
C. Acetylcysteine
Acetylcysteine is used as an antidote for acetaminophen (paracetamol) overdose, not for treating opioid-induced respiratory depression and hypotension.
D. Flumazenil
Flumazenil is a medication used as a benzodiazepine antagonist to reverse the effects of benzodiazepine overdose or sedation.
Full Explanation
A. Naloxone is a medication used as an opioid antagonist to reverse the effects of opioid overdose, including respiratory depression and hypotension. In this scenario, the client's symptoms suggest opioid-induced respiratory depression, making naloxone the appropriate choice to reverse the effects of morphine.
B. Protamine sulfate is used to reverse the anticoagulant effects of heparin, not for treating opioid-induced respiratory depression and hypotension.
C. Acetylcysteine is used as an antidote for acetaminophen (paracetamol) overdose, not for treating opioid-induced respiratory depression and hypotension.
D. Flumazenil is a medication used as a benzodiazepine antagonist to reverse the effects of benzodiazepine overdose or sedation.
A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?
A. Apply mitten restraints to prevent the client from disconnecting their tube feeding.
In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
B. Apply a vest restraint daily at bedtime to prevent nighttime wandering.
Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
C. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation.
The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Apply soft heel protectors bilaterally while client is in bed.
Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.
Full Explanation
Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
A. Weight gain
Weight gain occurs due to accumulation of fluid in the body due to back pressure into the system circulation.
B. Distended abdomen
Distended abdomen occurs due to fluid accumulation due to reduced stroke volume.
C. Confusion
While confusion can be a symptom of decreased cardiac output, it's not as specific as dyspnea in this case. Confusion can have various causes, including hypoxia, electrolyte imbalances, or medication side effects.
D. Dyspnea
This is a common symptom of left-sided heart failure. When the left ventricle fails to pump blood effectively, fluid backs up into the lungs, causing shortness of breath.
Full Explanation
A. Weight gain occurs due to accumulation of fluid in the body due to back pressure into the system circulation.
B. Distended abdomen occurs due to fluid accumulation due to reduced stroke volume.
C. While confusion can be a symptom of decreased cardiac output, it's not as specific as dyspnea in this case. Confusion can have various causes, including hypoxia, electrolyte imbalances, or medication side effects.
D. This is a common symptom of left-sided heart failure. When the left ventricle fails to pump blood effectively, fluid backs up into the lungs, causing shortness of breath.