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. An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding?

• A. Non-blanching
• B. Blanching
• C. Redness
• D. Warmth

Correct answer: B

Rationale:

3. What device would be best to use for a client who is immobile?

• A. Standing assist device
• B. A mechanical lift
• C. Transfer board
• D. Gait belt

Correct answer: B

Rationale: A mechanical lift is the most suitable device for a client who is immobile as it provides safe and efficient assistance in moving the individual. A standing assist device is used for support during standing activities, not for transferring an immobile client. A transfer board is helpful for assisting a client in sliding from one surface to another but may not be the best option for someone who is completely immobile. A gait belt is used for providing support and stability during walking or transferring, which may not be effective for a client who is immobile and requires more comprehensive assistance.

4. The nurse uses proper body mechanics to move a client up in bed. What action by the nurse will increase their risk of a workplace injury?

• A. Place the bed in the lowest possible position
• B. Use the legs when lifting
• C. Keep feet apart to provide a wide base of support
• D. Face the direction of the movement

Correct answer: A

Rationale: Placing the bed in the lowest possible position increases the risk of injury because it does not support proper body mechanics. When lifting a client, it is important to have the bed at a comfortable height to avoid strain. Using the legs when lifting (choice B) is correct as it reduces the strain on the back. Keeping feet apart to provide a wide base of support (choice C) helps with stability and balance. Facing the direction of the movement (choice D) is essential for maintaining proper alignment and reducing the risk of injury.

5. What is a priority intervention when caring for a client in Buck’s traction?

• A. Adjust the size of the traction weights PRN as needed
• B. Discontinue the traction once the client has pain relief
• C. Ensure the traction weights rest on the floor
• D. Assess skin integrity

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.

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