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. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

• A. Position the client on one side with the head turned towards you
• B. Handle dentures with care
• C. Use gentle brushing and flossing techniques for clients with fragile mucosa
• D. Have a suction apparatus ready at the bedside

Correct answer: A

Rationale:

3. By providing measures to reduce skin breakdown, how does the nurse break the chain of infection?

• A. Sterilizing the area to reduce the reservoir risk
• B. Maintaining the integrity of a portal of entry
• C. Creating a reservoir to decrease the risk of infection
• D. Creating a susceptible host

Correct answer: B

Rationale:

4. A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?

• A. Administer glucosamine supplements
• B. Turn the client every 2 hours
• C. Provide active range of motion (ROM)
• D. Provide passive range of motion (ROM)

Correct answer: D

Rationale: The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.

5. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?

• A. Amount
• B. Consistency
• C. Heat
• D. Odor

Correct answer: C

Rationale:

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