Nursing Elites

1. The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?

• A. Offer the client protein with meals to promote healing
• B. Remove the old dressing with clean gloves
• C. Teach the client about nonpharmacological pain control methods
• D. Check medication administration record (MAR)for as needed orders (PRN)

Correct answer: C

Rationale:

2. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?

• A. Amount
• B. Consistency
• C. Heat
• D. Odor

Correct answer: C

Rationale:

3. What is the term for a ringing in the ears reported by the client?

• A. Weber
• B. Rinne
• C. Pinna
• D. Tinnitus

Correct answer: D

Rationale: Tinnitus is the correct answer. Tinnitus refers to the perception of noise or ringing in the ears. This condition can be constant or intermittent and may be caused by various factors such as exposure to loud noises, ear infections, or underlying health conditions. Choices A, B, and C are incorrect as Weber and Rinne tests are related to hearing assessment, while the pinna is the external part of the ear responsible for collecting sound waves.

4. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

• A. The nurse assesses capillary refill of 2 seconds
• B. The nurse cannot insert one finger between the cast and the skin
• C. The nurse finds 2+ pulses distal from the cast
• D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

5. What is correct about a nursing diagnosis?

• A. It is a human response to disease, injury, or other stressors.
• B. It remains constant as long as the disease is present.
• C. It is a way to identify pathology.
• D. It is a disease, illness, or injury.

Correct answer: A

Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.

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