Nursing Elites

1. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

• A. The nurse assesses capillary refill of 2 seconds
• B. The nurse cannot insert one finger between the cast and the skin
• C. The nurse finds 2+ pulses distal from the cast
• D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

2. 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.

3. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?

• A. I will drink at least 3000 mL of water daily."?
• B. . 'I will shower every day in hot water."?
• C. I will avoid tights belts."?
• D. I will use a humidifier during the winter months."?

Correct answer: B

Rationale:

4. What occurs during stage three of bone healing?

• A. Consolidation
• B. Callus formation
• C. Granulation formation
• D. Hematoma formation

Correct answer: B

Rationale: During stage three of bone healing, callus formation occurs. This process involves the formation of a soft callus made of collagen and cartilage, which bridges the gap between bone fragments. Choice A, consolidation, typically happens in later stages and involves the hardening of the callus into mature bone. Choices C and D are incorrect as granulation formation and hematoma formation occur in earlier stages of bone healing, specifically stages one and two, respectively.

5. What is the priority nursing diagnosis for a client with metastatic bone disease?

• A. Chronic pain
• B. Impaired mobility
• C. Risk for falls
• D. Risk for infection

Correct answer: C

Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.

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