Nursing Elites

1. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?

• A. Amputation
• B. Deep vein thrombosis
• C. Internal bleeding
• D. Kidney failure

Correct answer: B

Rationale:

2. 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.

3. What evaluation indicates successful progress on the client goal of increasing daily physical activity?

• A. The client reports decreased social interaction
• B. The client reports more nonsteroidal anti-inflammatory drug (NSAID) use
• C. The client reports a fall
• D. The client reports less fatigue walking up stairs

Correct answer: D

Rationale: The correct answer is D because reporting less fatigue when walking up stairs indicates improved physical endurance, showing progress in increasing daily activity. Choices A, B, and C are incorrect because decreased social interaction, increased NSAID use, and experiencing a fall are not indicators of successful progress in increasing daily physical activity.

4. The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?

• A. The client instills the prescribed number of eye drops into the conjunctival sac
• B. The client sets the cap to the eye drop container down in a manner that does not contaminate it
• C. The client touches the administration dropper her to the eye
• D. The client washes her hands before instilling the eye drops

Correct answer: C

Rationale:

5. 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:

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