Nursing Elites

1. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

• A. Administer antibiotics to the client
• B. Increase the client's protein intake
• C. Teach relaxation breathing to reduce the client's pain
• D. Provide the client with anti-pyretic therapy

Correct answer: A

Rationale:

2. 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.

3. 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:

4. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

• A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
• B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
• C. The UAP carefully empties the indwelling catheter bag
• D. The UAP shows the client how to use the call light

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.

5. 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:

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