Nursing Elites

1. Most adults with human immunodeficiency virus will exhibit which of the following laboratory values?

• A. Higher than normal number of CD4+ T-cells and CD8+ T-cells are normal
• B. Lower than normal number of CD4+ T-cells and higher than normal CD8+ T-cells
• C. Higher than normal number of CD4+ T-cells and CD8+ T-cells are low
• D. Lower than normal number of CD4+ T-cells and CD8+ T-cells are normal

Correct answer: D

Rationale:

2. 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:

3. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?

• A. Use a mechanical lift to reposition the client every 2 hours
• B. Elevate the client's head of the bed to 45 degrees
• C. Postpone daily bed bath
• D. Caregiver independently slides the client up in the bed

Correct answer: A

Rationale:

4. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

• A. The nurse assesses capillary refill of 2 seconds
• B. The nurse cannot insert one finger between the cast and the skin
• C. The nurse finds 2+ pulses distal from the cast
• D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

5. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?

• A. The client reports chronic fatigue
• B. The client has a butterfly rash
• C. Blood pressure of 126/85 mm Hg
• D. Urine output of 20 mL/hour

Correct answer: D

Rationale:

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