Nursing Elites

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

• A. Palpate for edema
• B. Auscultate for bowel sounds
• C. Inspect the skin for injury
• D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

2. A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the client education?

• A. Avoid exercise during flare-ups
• B. Do high impact exercises like running
• C. Establish a regular sleep pattern
• D. Increase calcium and caffeine intake

Correct answer: C

Rationale:

3. Which nonpharmacological intervention does not help reduce edema?

• A. Heat therapy
• B. Passive range of motion (PROM)
• C. Elevation of the extremity
• D. Cold therapy

Correct answer: A

Rationale: The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.

4. On inspection, which client does the nurse suspect of having a visual impairment?

• A. The client whose sclera is white
• B. The client who has an intact blink reflex
• C. The client who is tilting their head
• D. The client with equal pupils

Correct answer: C

Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.

5. An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding?

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

Correct answer: B

Rationale:

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