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 client has a new arm cast. What is incorrect teaching by the nurse?

• A. Use a sling to alleviate fatigue
• B. Elevate the arm above the heart to reduce swelling
• C. Report ‘hot spots’ felt under the cast
• D. Sudden increase in drainage is expected

Correct answer: D

Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.

3. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

4. The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?

• A. Offer the client protein with meals to promote healing
• B. Remove the old dressing with clean gloves
• C. Teach the client about nonpharmacological pain control methods
• D. Check medication administration record (MAR)for as needed orders (PRN)

Correct answer: C

Rationale:

5. The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time and he denies any type of eye pain. Which eye disorder should the nurse suspects the clients has?

• A. Cataracts
• B. Diabetic retinopathy
• C. Corneal dystrophy
• D. Conjunctivitis

Correct answer: A

Rationale:

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