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. The nurse is caring for 4 clients. Which of these clients will the nurse see first?

• A. A client with rheumatoid arthritis and a scheduled pain medication
• B. A client being discharged in 2 hours and needs to be taught how to use crutches
• C. A client with sudden and increasing pain in a fractured arm
• D. A client with a fractured ankle who would like a glass of water

Correct answer: C

Rationale: The correct answer is C because sudden and increasing pain in a fractured arm indicates a potential complication that requires immediate attention to assess and manage. Choices A, B, and D do not present immediate life-threatening situations or emergent needs compared to sudden and increasing pain in a fractured arm, which takes priority to ensure the client's safety and comfort.

3. To promote independence, which of these is the best intervention to implement?

• A. Perform the client’s activities of daily living for them.
• B. Speak directly in front of the client so they can read your lips well.
• C. Give the client their washcloth and toothbrush and leave the room.
• D. Allow the client to perform the activities of daily living they are able to do.

Correct answer: D

Rationale: The correct answer is to allow the client to perform the activities of daily living they are able to do. This intervention promotes independence by encouraging clients to maintain their functional abilities. Choice A is incorrect as performing the client's activities of daily living for them does not empower independence. Choice B is irrelevant to promoting independence. Choice C is not actively promoting independence as it involves leaving the client alone without any guidance or support.

4. On inspection, which client does the nurse suspect of having a visual impairment?

• A. The client whose sclera is white
• B. The client who has an intact blink reflex
• C. The client who is tilting their head
• D. The client with equal pupils

Correct answer: C

Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.

5. 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:

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