Nursing Elites

1. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?

• A. Diagnosis
• B. Assessment
• C. Implementation
• D. Evaluation

Correct answer: B

Rationale:

2. A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him up in bed. What force caused the injury?

• A. Shearing or friction
• B. Twisting and bending
• C. Pressure or gravity
• D. Chemical or pressure

Correct answer: A

Rationale:

3. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?

• A. Maintain the client's blood pressure
• B. Call a chaplain
• C. Provide the spouse a chair
• D. Ask the client's spouse to explain what happened

Correct answer: A

Rationale:

4. What soft tissue musculoskeletal injury is excessive stretching of a ligament?

• A. Sprain
• B. Ligament tear
• C. Strain
• D. Tendon rupture

Correct answer: A

Rationale: A sprain is an injury involving excessive stretching of a ligament.

5. What evaluation indicates successful progress on the client goal of increasing daily physical activity?

• A. The client reports decreased social interaction
• B. The client reports more nonsteroidal anti-inflammatory drug (NSAID) use
• C. The client reports a fall
• D. The client reports less fatigue walking up stairs

Correct answer: D

Rationale: The correct answer is D because reporting less fatigue when walking up stairs indicates improved physical endurance, showing progress in increasing daily activity. Choices A, B, and C are incorrect because decreased social interaction, increased NSAID use, and experiencing a fall are not indicators of successful progress in increasing daily physical activity.

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