Nursing Elites

1. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?

• A. Mental state
• B. Friction and shear
• C. Nutrition
• D. Sensory perception

Correct answer: A

Rationale:

2. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

• A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
• B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
• C. The UAP carefully empties the indwelling catheter bag
• D. The UAP shows the client how to use the call light

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.

3. 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:

4. What is correct health promotion education for vision? (Select all that apply)

• A. Wear sunglasses to filter ultraviolet (UV) light
• B. Avoid nonsteroidal anti-inflammatory drug (NSAID) use
• C. Wash your hands before touching your eyelids
• D. All of The Above

Correct answer: D

Rationale: Wearing sunglasses, washing hands before touching eyelids, and wearing eye protection when working with fluids are important health promotion activities for vision.

5. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

• A. Administer antibiotics to the client
• B. Increase the client's protein intake
• C. Teach relaxation breathing to reduce the client's pain
• D. Provide the client with anti-pyretic therapy

Correct answer: A

Rationale:

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