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 states that he has been experiencing oozing from his wounds. What is the nurse's priority action?

• A. Insert the wound and assess the drainage
• B. Apply topical ointment to the wound
• C. Call the provider to initiate antibiotics
• D. Culture the wound

Correct answer: D

Rationale:

3. A client arrives speaking only Spanish. What is the priority nursing intervention?

• A. Give the client a tour of the unit
• B. Verify the reason for admission
• C. Request a medical interpreter
• D. Call the chaplain for support

Correct answer: C

Rationale:

4. The medical record for a client states that the client has hemiplegia. What does this mean?

• A. The client can use his right arm, left leg, and left arm.
• B. The client has paralysis of all four extremities.
• C. The client has decreased vision in one eye.
• D. The client has paralysis on one side of the body.

Correct answer: D

Rationale: Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.

5. A nurse is caring for a client who is post-operative following an open reduction internal fixation (ORIF) of a femur fracture. What is NOT included in the evaluation of the neurovascular status of the client's affected extremity?

• A. Color
• B. Temperature
• C. Sensation
• D. Skin integrity

Correct answer: D

Rationale:

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