Nursing Elites

1. The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?

• A. Stage 3
• B. Stage 4
• C. Stage 1
• D. Stage 2

Correct answer: D

Rationale:

2. A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?

• A. Skin turgor
• B. Lung sounds
• C. Radial pulses
• D. Capillary refill

Correct answer: B

Rationale:

3. A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next?

• A. Remove the cast to decrease pressure
• B. Raise the arm above the level of the heart
• C. Apply heat to the affected hand
• D. Encourage range of motion

Correct answer: B

Rationale:

4. 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.

5. What health teaching would not help an older adult avoid a musculoskeletal injury?

• A. Avoid home modification
• B. Wear a helmet when riding a bicycle
• C. Osteoporosis screening
• D. Fall prevention

Correct answer: A

Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.

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