Nursing Elites

1. After repositioning an immobile client, the nurse observes an area of hyperemia. What action should the nurse take to assess for blanching?

• A. Document the presence in the client’s record.
• B. Apply light pressure over the area.
• C. Apply heat to the area and reassess in 30 minutes.
• D. Apply cold compresses to reduce the redness.

Correct answer: B

Rationale: The correct action for the nurse to take to assess for blanching in an area of hyperemia is to apply light pressure over the area. Blanching is the temporary whitening of the skin when pressure is applied and then released, indicating that the blood flow is returning to the area. Applying light pressure helps in determining if the hyperemic area blanches, ensuring that blood flow is adequate. Choices A, C, and D are incorrect because documenting findings, applying heat, or using cold compresses are not appropriate actions for assessing blanching in an area of hyperemia.

2. The nurse observes that a client’s wrist restraint is secured to the side rail of the bed. What action should the nurse take?

• A. Ensure that the restraint is snug against the client’s wrist.
• B. Reposition the restraint tie onto the bedframe.
• C. Double knot the restraint to ensure safety.
• D. Leave the restraint in place and notify the healthcare provider.

Correct answer: B

Rationale: The correct action for the nurse to take is to reposition the restraint tie onto the bedframe. Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted. Choice A is incorrect because the issue is with the attachment point, not the snugness of the restraint. Choice C is incorrect as double knotting the restraint does not address the incorrect attachment point. Choice D is incorrect as the nurse should not leave the restraint in the wrong position; instead, it should be moved to the correct location on the bedframe.

3. The nurse assesses a client’s wound. What type of wound requires immediate intervention by the nurse?

• A. Laceration
• B. Abrasion
• C. Contusion
• D. Ulceration

Correct answer: A

Rationale: Lacerations, especially deep ones, are prone to bacterial contamination and may require immediate intervention to prevent infection. Abrasions, contusions, and ulcerations are not as likely to lead to immediate serious complications like infections as lacerations.

4. A client with a fractured femur is placed in skeletal traction. What action should the nurse prioritize?

• A. Ensure that the weights are freely hanging.
• B. Place pillows under the client's knees.
• C. Adjust the weights to alleviate discomfort.
• D. Ensure that the traction ropes are free of knots.

Correct answer: A

Rationale: The correct action the nurse should prioritize when a client is placed in skeletal traction for a fractured femur is to ensure that the weights are freely hanging. This is crucial to maintain proper alignment of the bone and prevent complications. Placing pillows under the client's knees (Choice B) is not a priority in skeletal traction. Adjusting the weights to alleviate discomfort (Choice C) should not be done without proper orders from the healthcare provider. Ensuring that the traction ropes are free of knots (Choice D) is important but ensuring the weights hang freely is the priority to maintain traction effectiveness.

5. When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?

• A. To reduce abdominal pressure on the diaphragm
• B. To promote oxygenation by improving lung expansion
• C. To encourage use of accessory muscles for breathing
• D. To drain secretions and prevent aspiration

Correct answer: D

Rationale: Elevating the head of the bed in a client with acute respiratory distress syndrome (ARDS) is essential to drain secretions and prevent aspiration. This position helps facilitate the removal of secretions from the airways, reducing the risk of aspiration pneumonia. Choices A, B, and C are incorrect as the primary reason for elevating the head of the bed in ARDS is to assist with secretion drainage and prevent complications associated with aspiration.

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