Nursing Elites

1. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?

• A. Observe client for changes in mental status
• B. Use aseptic technique for wound care and emptying of drains
• C. Keep the client's heels off the bed
• D. Perform neurovascular assessments per protocol

Correct answer: D

Rationale:

2. What nursing interventions increase the risk the pressure injuries?

• A. Padding hard surfaces
• B. Have client sit in wheelchair as much as possible
• C. Place pillows between bony surfaces
• D. Keep head of bed (HOB) at or less than 3

Correct answer: B

Rationale:

3. By providing measures to reduce skin breakdown, how does the nurse break the chain of infection?

• A. Sterilizing the area to reduce the reservoir risk
• B. Maintaining the integrity of a portal of entry
• C. Creating a reservoir to decrease the risk of infection
• D. Creating a susceptible host

Correct answer: B

Rationale:

4. A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?

• A. Collect a culture of the purulent fluid
• B. Cleanse the skin around the pins
• C. Administer an antibiotic
• D. Instruct the client to complete exercise of the affected extremity

Correct answer: A

Rationale:

5. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

• A. Creamy pus
• B. Serous
• C. Serosanguineous
• D. Purulent exudate

Correct answer: C

Rationale:

Similar Questions