Nursing Elites

1. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

• A. Remove the nursing diagnosis in the plan of care since it has not occurred
• B. Change the nursing diagnosis in plan of care to impaired mobility
• C. Modify the nursing diagnosis in plan of care to impaired skin integrity
• D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present

Correct answer: D

Rationale:

2. What level of Maslow's Hierarchy of needs does shelter belong to?

• A. Love and belonging
• B. Physiological
• C. Safety and security
• D. Esteem

Correct answer: C

Rationale:

3. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

• A. Stage III pressure injury
• B. A stage II pressure injury
• C. A non-staging pressure injury
• D. Stage IV pressure injury

Correct answer: D

Rationale:

4. What statement by the client with plantar fasciitis indicates a need for further teaching?

• A. I will use warm packs on my feet.
• B. I will use nonsteroidal anti-inflammatory drugs (NSAIDS) for comfort.
• C. I will rest and stretch my feet.
• D. I will wear supportive shoes.

Correct answer: A

Rationale: The correct answer is A. Using warm packs can exacerbate inflammation in plantar fasciitis. Choices B, C, and D are all appropriate interventions for managing plantar fasciitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation. Resting and stretching the feet can promote healing and reduce symptoms. Wearing supportive shoes can provide stability and reduce strain on the plantar fascia. Therefore, the client's statement about using warm packs indicates a need for further teaching as it can worsen the condition.

5. A nurse is caring for an immobile client. What is the priority assessment of this client?

• A. Palpate for edema
• B. Auscultate for bowel sounds
• C. Inspect the skin for injury
• D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

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