Nursing Elites

1. Which finding is not typically associated with inflammation in a client?

• A. Pain
• B. Heat
• C. Polyuria
• D. Erythema

Correct answer: C

Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.

2. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

3. What is the best goal for pain control in a client with RA?

• A. The client will eat healthy meals today and stay hydrated
• B. The client will have throughout the entire day
• C. The client will have pain less than 3/10 for most of the day
• D. The client will have pain less than 8/10 throughout the day

Correct answer: D

Rationale:

4. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don?

• A. PAPR mask
• B. Sterile gloves
• C. Gown
• D. Surgical mask

Correct answer: C

Rationale:

5. Which assessment is NOT a nonverbal sing of pain?

• A. Decreased attention span
• B. Grimacing
• C. Increase in heart rate
• D. Reported pain of 5/10

Correct answer: D

Rationale:

Similar Questions