Nursing Elites

1. 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.

2. What client is a susceptible host most at risk for infection?

• A. A client with leukemia
• B. A hospitalized 35-year-old-client
• C. A child who is immunized
• D. A 60-year-old client

Correct answer: A

Rationale:

3. What is one of the earliest signs of fat embolism syndrome?

• A. Paresthesia
• B. Severe pain in the affected limb unrelieved by medication
• C. Edema
• D. Hypoxemia

Correct answer: D

Rationale: Hypoxemia is one of the earliest signs of fat embolism syndrome. In fat embolism syndrome, fat globules enter the bloodstream and can obstruct blood flow in the lungs, leading to hypoxemia. Paresthesia, severe pain unrelieved by medication, and edema are not typically among the earliest signs of fat embolism syndrome.

4. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)

• A. A client on birth control pills
• B. A client who is immobile
• C. A client on an anticoagulant
• D. A client with dementia who has been wandering

Correct answer: a

Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.

5. 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:

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