Nursing Elites

1. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?

• A. An adolescent who has a patella fracture and is in an immobilizer
• B. A young adult who has a femur fracture and is going to surgery in two hours
• C. A middle-aged adult who has fractured his radius and has a cast
• D. An older adult who has a hip fracture and is immobile

Correct answer: D

Rationale:

2. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

• A. Client will increase mobility by the time of discharge from hospital
• B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
• C. Client will increase activity tolerance by discharge from the hospital
• D. Client will remain free from falls throughout their hospital stay

Correct answer: D

Rationale:

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. A client with systemic lupus erythematous complains of flank pain. Which laboratory test does the nurse anticipate will be ordered?

• A. Platelets
• B. Skin biopsy
• C. Creatinine
• D. Hemoglobin

Correct answer: C

Rationale:

5. 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:

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