Nursing Elites

1. A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?

• A. Inquire about the frequency, quality and location of the pain
• B. Get the client pain medication
• C. Ensure the client knows he will have negative effects from immobility
• D. Review the client’s medication administration record

Correct answer: A

Rationale: Assessing the pain characteristics helps in managing the client’s pain effectively.

2. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?

• A. An adolescent who has a patella fracture and is in an immobilizer
• B. A young adult who has a femur fracture and is going to surgery in two hours
• C. A middle-aged adult who has fractured his radius and has a cast
• D. An older adult who has a hip fracture and is immobile

Correct answer: D

Rationale:

3. What is correct about a nursing diagnosis?

• A. It is a human response to disease, injury, or other stressors.
• B. It remains constant as long as the disease is present.
• C. It is a way to identify pathology.
• D. It is a disease, illness, or injury.

Correct answer: A

Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.

4. A client with chronic osteomyelitis is being discharged from the hospital. What is the nurse’s priority discharge intervention?

• A. Teaching adherence to an exercise program
• B. Teaching about a healthy dietary intake
• C. Teaching adherence to the antibiotic regimen
• D. Scheduling daily dressing changes

Correct answer: C

Rationale: The correct answer is C: Teaching adherence to the antibiotic regimen. In chronic osteomyelitis, the priority is to ensure proper treatment of the infection, which heavily relies on consistent adherence to the prescribed antibiotic regimen. This helps in eradicating the infectious organisms and preventing recurrence. Choices A, B, and D are important aspects of care but teaching adherence to the antibiotic regimen takes precedence as it directly impacts the successful management of chronic osteomyelitis.

5. 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.

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