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. What nursing intervention is best to improve communication with a hearing-impaired client?

• A. Speak slowly and clearly while facing the client
• B. Write down the message
• C. Talk in a regular voice in the good ear
• D. Shout in the impaired

Correct answer: A

Rationale: Speaking slowly and clearly while facing the client improves communication with hearing-impaired clients.

3. 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:

4. When providing a routine bed bath, what action does the nurse complete first?

• A. Cleanse the client's feet
• B. Cleanse the client's hands
• C. Cleanse the client's perineal area
• D. Cleanse the client's face

Correct answer: D

Rationale:

5. 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.

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