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. Which assessment is NOT a nonverbal sing of pain?

• A. Decreased attention span
• B. Grimacing
• C. Increase in heart rate
• D. Reported pain of 5/10

Correct answer: D

Rationale:

3. A client has cellulitis on his left arm. What statement by the client indicates understanding of symptom management?

• A. "I can use tight bandages on my arm."?
• B. "I should not apply heat to my arm."?
• C. "I can use a warm, moist towel on my arm."?
• D. "I should use a cold, dry source on my arm."?

Correct answer: C

Rationale:

4. What is a negative effect of immobility on the cardiovascular system?

• A. Increased high density lipoprotein
• B. Increased circulation
• C. Increased pumping action of the heart
• D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.

5. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?

• A. Assess the right radial pulse
• B. Call the provider
• C. Administer pain medication
• D. Assess the right pedal pulse

Correct answer: A

Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.

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