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. What nursing intervention is best to improve communication with a hearingimpaired client?

• A. Talk in a regular voice in the good ear
• B. Talk loudly in the impaired ear
• C. Write down the message
• D. Speak slowly and clearly while facing the client

Correct answer: D

Rationale:

3. Which of the following clients should be placed in isolation for airborne precautions?

• A. A high school wrestling championship with a rash
• B. A client that recently travelled and developed a fever with cough
• C. A client with an unknown skin infection
• D. A client with heart palpitations

Correct answer: B

Rationale:

4. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

• A. Client will increase mobility by the time of discharge from hospital
• B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
• C. Client will increase activity tolerance by discharge from the hospital
• D. Client will remain free from falls throughout their hospital stay

Correct answer: D

Rationale:

5. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?

• A. Assess the right radial pulse
• B. Call the provider
• C. Administer pain medication
• D. Assess the right pedal pulse

Correct answer: A

Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.

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