Nursing Elites

1. A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?

• A. Traumatic injury
• B. Pressure injury
• C. Friction injury
• D. Shearing injury

Correct answer: D

Rationale:

2. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?

• A. Applying moisturizer to dry areas of the skin
• B. Massaging the client's reddened shoulders and heels
• C. Cleansing the skin routinely after soiling occurs
• D. Using a Hoyer lift for all transfers

Correct answer: B

Rationale:

3. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?

• A. Label the specimen tube
• B. Put on non-sterile gloves
• C. Gently remove the soiled dressings
• D. Irrigate the wound

Correct answer: B

Rationale:

4. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?

• A. The client reports chronic fatigue
• B. The client has a butterfly rash
• C. Blood pressure of 126/85 mm Hg
• D. Urine output of 20 mL/hour

Correct answer: D

Rationale:

5. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?

• A. Mental state
• B. Friction and shear
• C. Nutrition
• D. Sensory perception

Correct answer: A

Rationale:

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