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. 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 as it can lead to blood clots.

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 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:

5. By providing measures to reduce skin breakdown, how does the nurse break the chain of infection?

• A. Sterilizing the area to reduce the reservoir risk
• B. Maintaining the integrity of a portal of entry
• C. Creating a reservoir to decrease the risk of infection
• D. Creating a susceptible host

Correct answer: B

Rationale:

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