Nursing Elites

1. A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him up in bed. What force caused the injury?

• A. Shearing or friction
• B. Twisting and bending
• C. Pressure or gravity
• D. Chemical or pressure

Correct answer: A

Rationale:

2. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

• A. Two-point gait
• B. Three-point gait
• C. Four-point gait
• D. Unaffected gait

Correct answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.

3. What is the nurse's priority action for a client with compromised immunity?

• A. Wash hands before entering the client's room
• B. Take the client's vital signs every 4 hours
• C. Determine whether it is temporary or permanent
• D. Teach the family members to receive the flu shot annually

Correct answer: A

Rationale:

4. A nurse assesses an audible grating sound (Crepitus) when a client with osteoarthritis moves his knees. What is the cause of this sound?

• A. A herniated disk in the diseased joint
• B. Pieces of bone and cartilage floating
• C. Popping bursae from standing
• D. Years of an autoimmune process

Correct answer: A

Rationale:

5. The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?

• A. 15 degrees
• B. 0 degrees
• C. 90 degrees
• D. 30 degrees

Correct answer: C

Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.

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