Nursing Elites

1. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?

• A. Position the client on one side with the head turned towards you
• B. Handle dentures with care
• C. Use gentle brushing and flossing techniques for clients with fragile mucosa
• D. Have a suction apparatus ready at the bedside

Correct answer: A

Rationale:

2. 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.

3. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?

• A. Send the client back to surgery
• B. Assess the wound for signs of dehiscence
• C. Call the provider immediately
• D. Prepare to culture the wound

Correct answer: B

Rationale:

4. What occurs during stage three of bone healing?

• A. Consolidation
• B. Callus formation
• C. Granulation formation
• D. Hematoma formation

Correct answer: B

Rationale: During stage three of bone healing, callus formation occurs. This process involves the formation of a soft callus made of collagen and cartilage, which bridges the gap between bone fragments. Choice A, consolidation, typically happens in later stages and involves the hardening of the callus into mature bone. Choices C and D are incorrect as granulation formation and hematoma formation occur in earlier stages of bone healing, specifically stages one and two, respectively.

5. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

• A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
• B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
• C. The UAP carefully empties the indwelling catheter bag
• D. The UAP shows the client how to use the call light

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.

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