Nursing Elites

1. A nurse assesses an area of skin over a bony prominence. What finding would be most concerning?

• A. Redness
• B. Non-blanching
• C. Blanching
• D. Warmth

Correct answer: A

Rationale:

2. What device would be best to use for a client who is immobile?

• A. Standing assist device
• B. A mechanical lift
• C. Transfer board
• D. Gait belt

Correct answer: B

Rationale: A mechanical lift is the most suitable device for a client who is immobile as it provides safe and efficient assistance in moving the individual. A standing assist device is used for support during standing activities, not for transferring an immobile client. A transfer board is helpful for assisting a client in sliding from one surface to another but may not be the best option for someone who is completely immobile. A gait belt is used for providing support and stability during walking or transferring, which may not be effective for a client who is immobile and requires more comprehensive assistance.

3. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

4. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?

• A. Encouraging bedrest
• B. Applying antiembolism stockings
• C. Tell the client to take anticoagulants
• D. Teaching about smoking cessation

Correct answer: B

Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.

5. What are signs of hearing loss? (Select all that apply)

• A. Answering questions correctly
• B. Presence of cerumen
• C. Tinnitus
• D. Frequent asking of others to repeat statements

Correct answer: C

Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.

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