Nursing Elites

1. The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?

• A. Because it is easy to digest.'
• B. Protein has amin acid that promotes wound healing.'
• C. If you do not like it, you do not have to take it.'
• D. These supplements have nothing to do with your wound,'

Correct answer: B

Rationale:

2. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?

• A. An adolescent who has a patella fracture and is in an immobilizer
• B. A young adult who has a femur fracture and is going to surgery in two hours
• C. A middle-aged adult who has fractured his radius and has a cast
• D. An older adult who has a hip fracture and is immobile

Correct answer: D

Rationale:

3. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

• A. Assist the client to orthopneic position
• B. Offer a protein rich diet
• C. Offer the client a bedpan for toileting
• D. Turn the client every 4 hours

Correct answer: A

Rationale: The orthopneic position helps improve lung expansion, reducing the risk of atelectasis.

4. The client had surgery one day ago. What assessment is most likely related to pain?

• A. Blood pressure of 175/90 mm Hg
• B. Respirations of 10 breaths per minute
• C. Heart rate 60 beats/minute
• D. Oxygen saturation of 97%

Correct answer: A

Rationale:

5. What device would be best to use for a client who is immobile?

• A. Standing assist device
• B. A mechanical lift
• C. Transfer board
• D. Gait belt

Correct answer: B

Rationale: A mechanical lift is the most suitable device for a client who is immobile as it provides safe and efficient assistance in moving the individual. A standing assist device is used for support during standing activities, not for transferring an immobile client. A transfer board is helpful for assisting a client in sliding from one surface to another but may not be the best option for someone who is completely immobile. A gait belt is used for providing support and stability during walking or transferring, which may not be effective for a client who is immobile and requires more comprehensive assistance.

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