Nursing Elites

1. The nurse is caring for 4 clients. What client should the nurse see first?

• A. A client with multiple children visiting
• B. A client with lupus asking for dinner
• C. A client on Methotrexate with a fever
• D. A client with chronic rheumatic pain

Correct answer: C

Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.

2. Which of the following statements made by a client diagnosed with human immunodefiency virus (HIV) would require further teaching?

• A. "I will have to be careful and avoid crowds."?
• B. "I will take prescribed medications."?
• C. "I will have to take medications for the rest of my life."?
• D. "I will only need to take HIV medications for 6 months, and I will be cured

Correct answer: D

Rationale:

3. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

4. 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.

5. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

• A. The pain will go away after the swelling decreases.
• B. That is phantom limb pain.
• C. Your foot has been amputated, so you are not having pain in that foot.
• D. On a scale of 0-10, how would you rate your pain?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.

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