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. When providing a routine bed bath, what action does the nurse complete first?

• A. Cleanse the client's feet
• B. Cleanse the client's hands
• C. Cleanse the client's perineal area
• D. Cleanse the client's face

Correct answer: D

Rationale:

3. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

• A. Assist the client to orthopneic position
• B. Offer a protein rich diet
• C. Offer the client a bedpan for toileting
• D. Turn the client every 4 hours

Correct answer: A

Rationale: The orthopneic position helps improve lung expansion, reducing the risk of atelectasis.

4. The nurse is caring for 4 clients. Which of these clients will the nurse see first?

• A. A client with rheumatoid arthritis and a scheduled pain medication
• B. A client being discharged in 2 hours and needs to be taught how to use crutches
• C. A client with sudden and increasing pain in a fractured arm
• D. A client with a fractured ankle who would like a glass of water

Correct answer: C

Rationale: The correct answer is C because sudden and increasing pain in a fractured arm indicates a potential complication that requires immediate attention to assess and manage. Choices A, B, and D do not present immediate life-threatening situations or emergent needs compared to sudden and increasing pain in a fractured arm, which takes priority to ensure the client's safety and comfort.

5. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?

• A. The client's incision site has eviscerated
• B. The client's incision site has lacerated
• C. The client's incisional site is approximated
• D. The client's incisional site has dehisced after.

Correct answer: A

Rationale:

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