Nursing Elites

1. What is a priority intervention when caring for a client in Buck’s traction?

• A. Adjust the size of the traction weights PRN as needed
• B. Discontinue the traction once the client has pain relief
• C. Ensure the traction weights rest on the floor
• D. Assess skin integrity

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.

2. 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:

3. What is the priority nursing diagnosis after surgery to repair a fracture?

• A. Disturbed body image
• B. Risk for infection
• C. Risk for impaired skin integrity
• D. Acute pain

Correct answer: B

Rationale: The correct answer is B: Risk for infection. After surgery to repair a fracture, the priority nursing diagnosis is to monitor for the risk of infection to promote proper healing. Infections can significantly delay the healing process and lead to further complications. Choices A, C, and D are not the priority immediately post-surgery. Disturbed body image, risk for impaired skin integrity, and acute pain may be concerns but are not the priority in the immediate post-operative period following fracture repair.

4. What is the condition called when the client's pupils are different sizes and have been this way since childhood?

• A. Exophthalmos
• B. Anisocoria
• C. Strabismus
• D. Scleral edema

Correct answer: B

Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.

5. What is the best nursing intervention for a client with limited mobility who cannot move independently?

• A. Passive range of motion
• B. Pillows for positioning
• C. Active range of motion
• D. Continuous passive motion

Correct answer: A

Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.

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