Nursing Elites

1. A nurse is caring for an immobile client. What is the priority assessment in this client?

• A. Auscultation of lung sounds
• B. Assessment of skin turgor
• C. Auscultation of bowel sounds
• D. Assessment for the presence of peripheral edema

Correct answer: A

Rationale:

2. What nursing intervention is best to improve communication with a hearingimpaired client?

• A. Talk in a regular voice in the good ear
• B. Talk loudly in the impaired ear
• C. Write down the message
• D. Speak slowly and clearly while facing the client

Correct answer: D

Rationale:

3. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)

• A. A client on birth control pills
• B. A client who is immobile
• C. A client on an anticoagulant
• D. A client with dementia who has been wandering

Correct answer: a

Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.

4. A nurse is caring for a client who is post-operative following an open reduction internal fixation (ORIF) of a femur fracture. What is NOT included in the evaluation of the neurovascular status of the client's affected extremity?

• A. Color
• B. Temperature
• C. Sensation
• D. Skin integrity

Correct answer: D

Rationale:

5. What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?

• A. Tell the client’s family that they will be expected to stay overnight
• B. Apply restraints to the client
• C. Shout to the client
• D. Orient the client to the location of objects in the room

Correct answer: D

Rationale: The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.

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