Nursing Elites

1. What is an example of a client's primary defense to infection?

• A. Intact skin
• B. Inflammation
• C. Phagocytosis
• D. Fever

Correct answer: A

Rationale:

2. The nurse has documented the following wound assessment. "Shallow, open, reddened ulcer with no slough on the anterior region of the right heel?"? what stage is the wound?

• A. Stage 3
• B. Stage 4
• C. Stage 1
• D. Stage 2

Correct answer: D

Rationale:

3. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?

• A. Assess the right radial pulse
• B. Call the provider
• C. Administer pain medication
• D. Assess the right pedal pulse

Correct answer: A

Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.

4. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

• A. Remove the nursing diagnosis in the plan of care since it has not occurred
• B. Change the nursing diagnosis in plan of care to impaired mobility
• C. Modify the nursing diagnosis in plan of care to impaired skin integrity
• D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present

Correct answer: D

Rationale:

5. A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next?

• A. Remove the cast to decrease pressure
• B. Raise the arm above the level of the heart
• C. Apply heat to the affected hand
• D. Encourage range of motion

Correct answer: B

Rationale:

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