Nursing Elites

1. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?

• A. Use a mechanical lift to reposition the client every 2 hours
• B. Elevate the client's head of the bed to 45 degrees
• C. Postpone daily bed bath
• D. Caregiver independently slides the client up in the bed

Correct answer: A

Rationale:

2. What complication of fractures is caused by increased pressure which can result in decreased circulation to the area?

• A. Venous thromboembolism
• B. Acute compartment syndrome
• C. Fat embolism syndrome
• D. Hemorrhage

Correct answer: B

Rationale: Acute compartment syndrome is the correct answer. It involves increased pressure within muscles, leading to decreased blood flow and tissue damage. Venous thromboembolism (Choice A) is a condition where a blood clot forms in a vein, usually in the leg. Fat embolism syndrome (Choice C) occurs when fat globules enter the bloodstream and block blood vessels. Hemorrhage (Choice D) refers to bleeding, which can occur with fractures but does not specifically involve increased pressure leading to decreased circulation as in acute compartment syndrome.

3. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?

• A. The client's incision site has eviscerated
• B. The client's incision site has lacerated
• C. The client's incisional site is approximated
• D. The client's incisional site has dehisced after.

Correct answer: A

Rationale:

4. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?

• A. Diagnosis
• B. Assessment
• C. Implementation
• D. Evaluation

Correct answer: B

Rationale:

5. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

• A. The nurse assesses capillary refill of 2 seconds
• B. The nurse cannot insert one finger between the cast and the skin
• C. The nurse finds 2+ pulses distal from the cast
• D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

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