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. 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:

3. Which among the following is NOT the cause of pressure ulcers?

• A. Immobility
• B. Poor nutrition
• C. Moisture
• D. Adequate perfusion

Correct answer: D

Rationale:

4. What is the priority intervention for the nurse to enhance meeting the psychosocial needs of a client on transmission-based precautions?

• A. Allow the client sleep to build stamina
• B. Provide the client with diversional activities
• C. Maintain a six-foot distance from the client
• D. Provide a timeframe for the isolation

Correct answer: B

Rationale:

5. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

• A. Remove the nursing diagnosis in the plan of care since it has not occurred
• B. Change the nursing diagnosis in plan of care to impaired mobility
• C. Modify the nursing diagnosis in plan of care to impaired skin integrity
• D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present

Correct answer: D

Rationale:

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