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. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?

• A. Once retinal detachment occurs, it does not return to its normal state
• B. Once the tissue has necrosed from high-pressure, it does not regenerate
• C. Glaucoma always leads to permanent blindness
• D. Once bacterial infection has caused damage, the tissue does not regenerate

Correct answer: B

Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.

3. Which of the following nonpharmacological methods cannot be used to manage the chronic pain of a client with rheumatoid arthritis?

• A. Adequate rest
• B. Heat for 20-30 minutes
• C. Hot showers
• D. Ice for 2 hours at a time

Correct answer: D

Rationale:

4. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?

• A. Avoid contact sports until the infection has cleared
• B. Use a bath sponge to cleanse the skin
• C. Wash hands with soap and water before and after touching the infected area
• D. Use an antibacterial soap when showering

Correct answer: B

Rationale:

5. Which of the following is NOT a risk factor for osteoarthritis?

• A. Older age
• B. Sports injuries
• C. Obesity
• D. Vegan diet

Correct answer: D

Rationale:

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