Nursing Elites

1. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?

• A. Maintain the client's blood pressure
• B. Call a chaplain
• C. Provide the spouse a chair
• D. Ask the client's spouse to explain what happened

Correct answer: A

Rationale:

2. 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.

3. What is not an inappropriate nursing intervention for psoriasis?

• A. Teach the client how to utilize UV radiation
• B. Apply rubbing alcohol to plaques
• C. Apply corticosteroids as ordered
• D. Urge the client to consider participating in support groups

Correct answer: B

Rationale:

4. 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:

5. A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him up in bed. What force caused the injury?

• A. Shearing or friction
• B. Twisting and bending
• C. Pressure or gravity
• D. Chemical or pressure

Correct answer: A

Rationale:

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