Nursing Elites

1. A client has sustained an open fracture. What nursing intervention will best prevent osteomyelitis in this client?

• A. Delegate all client personal care to specific unlicensed assistive personnel
• B. Place the client in contact precautions
• C. Proper hand hygiene
• D. Administer pain medication

Correct answer: C

Rationale: Proper hand hygiene is crucial in preventing infections such as osteomyelitis in clients with open fractures. Keeping the hands clean helps reduce the risk of introducing harmful pathogens to the wound site. Delegating all client personal care to specific unlicensed assistive personnel (Choice A) is not appropriate as direct involvement in wound care is essential in preventing infections. Placing the client in contact precautions (Choice B) is not directly related to preventing osteomyelitis in this context. Administering pain medication (Choice D) is important for managing the client's pain but does not directly address the prevention of osteomyelitis.

2. A nurse is caring for an immobile client. What is the priority assessment of this client?

• A. Palpate for edema
• B. Auscultate for bowel sounds
• C. Inspect the skin for injury
• D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

3. While completing a health history the client reports experiencing blurring of vision in both eyes without associated pain. What condition does the nurse suspect?

• A. Macular degeneration
• B. Cataract
• C. Retinal detachment
• D. Glaucoma

Correct answer: B

Rationale: Cataracts can cause blurring of vision in both eyes without associated pain.

4. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?

• A. Label the specimen tube
• B. Put on non-sterile gloves
• C. Gently remove the soiled dressings
• D. Irrigate the wound

Correct answer: B

Rationale:

5. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

• A. The client refused her pain medication this morning and is doing physical therapy.
• B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
• C. The client reports intermittent flatus and minor abdominal discomfort.
• D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.

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