Nursing Elites

1. An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding?

• A. Non-blanching
• B. Blanching
• C. Redness
• D. Warmth

Correct answer: B

Rationale:

2. 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:

3. What is an example of a client's primary defense to infection?

• A. Intact skin
• B. Inflammation
• C. Phagocytosis
• D. Fever

Correct answer: A

Rationale:

4. A nurse is caring for a client who is post-operative following an open reduction internal fixation (ORIF) of a femur fracture. What is NOT included in the evaluation of the neurovascular status of the client's affected extremity?

• A. Color
• B. Temperature
• C. Sensation
• D. Skin integrity

Correct answer: D

Rationale:

5. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

• A. The client refused her pain medication this morning and is doing physical therapy.
• B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
• C. The client reports intermittent flatus and minor abdominal discomfort.
• D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.

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