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 nurse is caring for an immobile client. What is the priority assessment of this client?

• A. Palpate for edema
• B. Auscultate for bowel sounds
• C. Inspect the skin for injury
• D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

3. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?

• A. Deeply palpate the area for rebound tenderness
• B. Medicate the client for pain and reassess in 60 minutes
• C. Percuss over the area for a change in tone
• D. Compare the circumference to the left calf

Correct answer: D

Rationale:

4. A client has an abdominal incision. The surgical wound was closed with 10 sutures. This surgical wound is healing by what process?

• A. Primary intention
• B. Binary intention
• C. Secondary intention
• D. None of the Above

Correct answer: A

Rationale:

5. 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.

Similar Questions