Nursing Elites

1. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?

• A. Deeply palpate the area for rebound tenderness
• B. Medicate the client for pain and reassess in 60 minutes
• C. Percuss over the area for a change in tone
• D. Compare the circumference to the left calf

Correct answer: D

Rationale:

2. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

• A. Remove the nursing diagnosis in the plan of care since it has not occurred
• B. Change the nursing diagnosis in plan of care to impaired mobility
• C. Modify the nursing diagnosis in plan of care to impaired skin integrity
• D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present

Correct answer: D

Rationale:

3. 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.

4. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?

• A. The client sets the cap down in a manner that does not contaminate it.
• B. The client drops the prescribed number of drops into the conjunctival sac
• C. The client washes their hands before instilling the drops
• D. The client ensures that they touch the administration dropper to the eye

Correct answer: D

Rationale: Touching the dropper to the eye contaminates it and can lead to infection.

5. What should be done immediately after an ankle injury?

• A. Immobilize, heat, compress, and elevate the ankle
• B. Rest, ice, compress, and lower the ankle
• C. Rest, ice, compress, and elevate the ankle
• D. Rest, incubate, confine, and lower the ankle

Correct answer: C

Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.

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