Nursing Elites

1. A client arrives speaking only Spanish. What is the priority nursing intervention?

• A. Give the client a tour of the unit
• B. Verify the reason for admission
• C. Request a medical interpreter
• D. Call the chaplain for support

Correct answer: C

Rationale:

2. The medical record for a client states that the client has hemiplegia. What does this mean?

• A. The client can use his right arm, left leg, and left arm.
• B. The client has paralysis of all four extremities.
• C. The client has decreased vision in one eye.
• D. The client has paralysis on one side of the body.

Correct answer: D

Rationale: Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.

3. What is an example of a client's primary defense to infection?

• A. Intact skin
• B. Inflammation
• C. Phagocytosis
• D. Fever

Correct answer: A

Rationale:

4. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?

• A. Diagnosis
• B. Assessment
• C. Implementation
• D. Evaluation

Correct answer: B

Rationale:

5. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

• A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
• B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
• C. The UAP carefully empties the indwelling catheter bag
• D. The UAP shows the client how to use the call light

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.

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