Nursing Elites

1. What nursing interventions increase the risk the pressure injuries?

• A. Padding hard surfaces
• B. Have client sit in wheelchair as much as possible
• C. Place pillows between bony surfaces
• D. Keep head of bed (HOB) at or less than 3

Correct answer: B

Rationale:

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. A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is the first to occur?

• A. Tachycardia
• B. Raynaud's phenomenon
• C. Intense wrinkle
• D. Joint pain

Correct answer: B

Rationale:

4. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?

• A. Deliver upward abdominal thrusts with a fisted hand
• B. Perform a blind finger sweep of the child's mouth
• C. Complete five rapid back blows between the shoulder blades
• D. Encourage the child to continue coughing

Correct answer: D

Rationale:

5. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?

• A. Send the client back to surgery
• B. Assess the wound for signs of dehiscence
• C. Call the provider immediately
• D. Prepare to culture the wound

Correct answer: B

Rationale:

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