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. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?

• A. Mental state
• B. Friction and shear
• C. Nutrition
• D. Sensory perception

Correct answer: A

Rationale:

3. A nurse is teaching a newly hired group of unlicensed assistive personnel about infection-control measures on the unit. What is the most effective way to prevent the spread of pathogens during client care?

• A. Properly dispose of contaminated equipment
• B. Perform hand hygiene
• C. Discard used syringes into appropriate containers
• D. Change soiled linens

Correct answer: B

Rationale:

4. Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by health care workers?

• A. Wearing a mask within three feet of the client
• B. Using standard precautions
• C. Applying hand sanitizer to gloves during cares
• D. Double gloving

Correct answer: B

Rationale:

5. The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?

• A. The client instills the prescribed number of eye drops into the conjunctival sac
• B. The client sets the cap to the eye drop container down in a manner that does not contaminate it
• C. The client touches the administration dropper her to the eye
• D. The client washes her hands before instilling the eye drops

Correct answer: C

Rationale:

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