Nursing Elites

1. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?

• A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
• B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
• C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
• D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'

Correct answer: A

Rationale:

2. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

• A. The nurse assesses capillary refill of 2 seconds
• B. The nurse cannot insert one finger between the cast and the skin
• C. The nurse finds 2+ pulses distal from the cast
• D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

3. What is a negative effect of immobility on the cardiovascular system?

• A. Increased high density lipoprotein
• B. Increased circulation
• C. Increased pumping action of the heart
• D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.

4. Which assessment is NOT a nonverbal sing of pain?

• A. Decreased attention span
• B. Grimacing
• C. Increase in heart rate
• D. Reported pain of 5/10

Correct answer: D

Rationale:

5. 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.

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