Nursing Elites

1. What is the nurse's priority action for a client with compromised immunity?

• A. Wash hands before entering the client's room
• B. Take the client's vital signs every 4 hours
• C. Determine whether it is temporary or permanent
• D. Teach the family members to receive the flu shot annually

Correct answer: A

Rationale:

2. A client arrives speaking only Spanish. What is the priority nursing intervention?

• A. Give the client a tour of the unit
• B. Verify the reason for admission
• C. Request a medical interpreter
• D. Call the chaplain for support

Correct answer: C

Rationale:

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. 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.

5. A client has a fractured right arm. What should the nurse do first?

• A. Apply ice to the fracture site
• B. Administer pain medications
• C. Remove the client’s bracelet and rings from the right arm
• D. Send the client to radiology for an x-ray

Correct answer: C

Rationale: The nurse should first remove the client's bracelet and rings from the right arm. This action is crucial to prevent complications such as swelling and restricted blood flow, which could worsen the condition. Applying ice, administering pain medications, and sending the client for an x-ray are important steps but should come after ensuring the client's jewelry is removed to avoid any further issues.

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