Nursing Elites

1. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

• A. Stage III pressure injury
• B. A stage II pressure injury
• C. A non-staging pressure injury
• D. Stage IV pressure injury

Correct answer: D

Rationale:

2. The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time and he denies any type of eye pain. Which eye disorder should the nurse suspects the clients has?

• A. Cataracts
• B. Diabetic retinopathy
• C. Corneal dystrophy
• D. Conjunctivitis

Correct answer: A

Rationale:

3. 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:

4. The client had surgery one day ago. What assessment is most likely related to pain?

• A. Blood pressure of 175/90 mm Hg
• B. Respirations of 10 breaths per minute
• C. Heart rate 60 beats/minute
• D. Oxygen saturation of 97%

Correct answer: A

Rationale:

5. The nurse is providing medication for a client with osteomyelitis. What teaching should the nurse indicate in the education?

• A. The most common adverse e effect for nonsteroidal anti-inflammatory drugs (NSAIDS)are liver failure and tinnitus
• B. The main side effect of acetaminophen is gastrointestinal GI bleeding
• C. You should not take more than 4000 mg of acetaminophen a day
• D. Nonsteroidal anti-inflammatory drugs (NSAIDS) are very safe and are known to have no side effects

Correct answer: A

Rationale:

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