Joe Russo 446 AR

A 75-year-old patient with a Stage III sacral pressure ulcer has the following vital signs: BP 90/60 mmHg, HR 112 bpm, Temp 101.3°F (38.5°C), RR 24/min, SpO₂ 95%. Which finding should the nurse report immediately to the healthcare provider?

• White blood cell count of 17,000/mm³

• Blood pressure 90/60 mmHg with heart rate 112 bpm

• Stage III pressure ulcer with foul odor

• Glucose level of 158 mg/dL

Answer explanation

The blood pressure of 90/60 mmHg with a heart rate of 112 bpm indicates potential hypovolemic shock or sepsis, requiring immediate attention. Other findings, while concerning, do not necessitate urgent reporting.

The patient reports severe sacral pain rated 8/10. Which medication should the nurse administer?

• Morphine 2 mg IV every 4 hours PRN

• Oxycodone 5mg/325mg PO every 6 hours PRN

• Non-pharmacological measures only

• Ask the provider to increase the morphine dose

Answer explanation

Morphine 2 mg IV every 4 hours PRN is appropriate for severe pain (8/10). It provides rapid relief, while oral oxycodone may not act quickly enough. Non-pharmacological measures alone are insufficient for this level of pain.

The patient has a documented allergy to penicillin. Which prescription should the nurse question?

• Ceftriaxone IV

• Morphine IV

• Erythropoietin SQ

• Oxycodone PO

Answer explanation

Ceftriaxone is a cephalosporin antibiotic, which can have cross-reactivity in patients allergic to penicillin. Therefore, the nurse should question this prescription due to the patient's documented penicillin allergy.

The patient’s albumin level is 2.4 g/dL. What complication is he most at risk for?

• Hyperglycemia

• Poor wound healing

• Constipation

• Fluid volume overload

Answer explanation

A low albumin level (2.4 g/dL) indicates poor protein status, which can impair wound healing due to reduced collagen synthesis and immune function. Therefore, the patient is most at risk for poor wound healing.

Which nursing action is most effective in preventing the spread of infection from the sacral wound?

• Place the patient in airborne precautions

• Use sterile gloves for all dressing changes

• Perform hand hygiene before and after wound care

• Limit patient’s fluid intake

Answer explanation

Performing hand hygiene before and after wound care is the most effective action to prevent infection spread. It reduces the risk of transferring pathogens, making it essential for infection control.

The nurse reviews the order: “Consult dietary.” What should the nurse emphasize in patient teaching?

• Limit carbohydrates

• Increase intake of protein and iron-rich foods

• Avoid dairy products

• Reduce fat intake

Answer explanation

Increasing protein and iron-rich foods is crucial for overall health, especially in recovery or specific dietary needs. This choice supports muscle repair and enhances oxygen transport, which is often emphasized in dietary consultations.

Which lab result best supports the diagnosis of acute inflammation or infection?

• Hemoglobin 7.9 g/dL

• CRP 30 mg/L

• Albumin 2.4 g/dL

• Glucose 158 mg/dL

Answer explanation

CRP (C-reactive protein) is a marker of inflammation. A level of 30 mg/L indicates acute inflammation or infection, making it the best choice among the options. The other results do not specifically indicate inflammation.

The patient reports generalized weakness and pale complexion. What is the most likely cause?

• Elevated WBC count

• Hyperglycemia

• Anemia (Hgb 7.9 g/dL)

• Low albumin

Answer explanation

The patient's symptoms of generalized weakness and pale complexion are indicative of anemia, which is confirmed by the low hemoglobin level of 7.9 g/dL. Anemia commonly causes fatigue and pallor due to reduced oxygen-carrying capacity.

The patient is prescribed erythropoietin 2000 IU SQ for anemia. What should the nurse check before administration?

• Blood glucose level

• Blood pressure

• White blood cell count

• Potassium level

Answer explanation

Before administering erythropoietin, the nurse should check the blood pressure, as this medication can increase blood pressure. Monitoring is essential to prevent complications related to hypertension.

Wound cultures grow Klebsiella. What isolation precaution is indicated?

• Droplet precautions

• Airborne precautions

• Contact precautions

• Protective isolation

Answer explanation

Klebsiella is a bacterium that can be transmitted through direct contact. Therefore, contact precautions are indicated to prevent the spread of infection, making this the correct choice.