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 should be done immediately after an ankle injury?

• A. Immobilize, heat, compress, and elevate the ankle
• B. Rest, ice, compress, and lower the ankle
• C. Rest, ice, compress, and elevate the ankle
• D. Rest, incubate, confine, and lower the ankle

Correct answer: C

Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.

3. What complication of wound healing is an abnormal passage that connects two body cavities or a cavity and the skin?

• A. Fistula
• B. Hemorrhage
• C. Evisceration
• D. infection

Correct answer: A

Rationale:

4. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?

• A. I will drink at least 3000 mL of water daily."?
• B. . 'I will shower every day in hot water."?
• C. I will avoid tights belts."?
• D. I will use a humidifier during the winter months."?

Correct answer: B

Rationale:

5. A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is the first to occur?

• A. Tachycardia
• B. Raynaud's phenomenon
• C. Intense wrinkle
• D. Joint pain

Correct answer: B

Rationale:

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