Nursing Elites

1. While documenting client care, which entry should the nurse identify as an example of implementing client care?

• A. Documenting the client's pain level
• B. Monitoring the client's urine output
• C. Assessing the client's range of motion
• D. Contacting the provider to report client findings

Correct answer: D

Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.

2. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which client statement indicates an understanding of the teaching?

• A. Apply pressure directly to the wound
• B. Remove the dressings to assess the wound
• C. Use a clean dressing over the saturated one
• D. Apply alcohol to the wound

Correct answer: C

Rationale: The correct answer is C because placing a clean dressing over the saturated one helps maintain wound integrity and prevents further tissue damage. Choice A is incorrect as applying direct pressure to the wound is correct for controlling bleeding but not for dressing changes. Choice B is incorrect because removing dressings may disrupt wound healing and increase the risk of infection. Choice D is incorrect since applying alcohol to the wound can cause further irritation and damage to the tissues.

3. A healthcare professional is reviewing the health history of a client who has a hip fracture. What is a risk factor for developing pressure injuries?

• A. Increased fluid intake
• B. Urinary incontinence
• C. Poor nutrition
• D. Immobility

Correct answer: B

Rationale: Urinary incontinence is a risk factor for developing pressure injuries as it can lead to skin breakdown due to constant exposure to moisture and irritation. Increased fluid intake is important for hydration and overall health but is not directly linked to pressure injuries. Poor nutrition can impair wound healing but is not a direct risk factor for pressure injuries. Immobility can contribute to the development of pressure injuries but is not as directly related as urinary incontinence.

4. A healthcare provider is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare provider use?

• A. Verbal self-report
• B. Pain scale
• C. Behavioral indicators
• D. Observing facial expressions

Correct answer: C

Rationale: In clients with dementia and difficulty communicating, using behavioral indicators such as agitation and restlessness is more reliable for assessing pain than relying on verbal self-report, pain scales, or observing facial expressions. Verbal self-report may not be possible due to communication challenges, pain scales may be difficult for the client to comprehend, and observing facial expressions alone may not provide a comprehensive assessment of pain in individuals with dementia.

5. A healthcare provider is preparing to perform a routine abdominal assessment. What action should the healthcare provider take first?

• A. Inspect the abdomen
• B. Auscultate bowel sounds
• C. Palpate the abdomen
• D. Percuss the abdomen

Correct answer: A

Rationale: The correct first action in a routine abdominal assessment is to inspect the abdomen. This allows the healthcare provider to visually assess for any visible abnormalities such as scars, distention, or masses. Auscultating bowel sounds comes after inspection as the second step to assess bowel motility. Palpation and percussion follow in the sequence of a comprehensive abdominal assessment. Therefore, inspecting the abdomen is the priority to gather initial information before proceeding with further assessment techniques.

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