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. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

• A. Client will increase mobility by the time of discharge from hospital
• B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
• C. Client will increase activity tolerance by discharge from the hospital
• D. Client will remain free from falls throughout their hospital stay

Correct answer: D

Rationale:

3. The nurse is caring for 4 clients. Which of these clients will the nurse see first?

• A. A client with sudden and increasing pain in his fractured arm
• B. A client being discharged in 2 hours and needs to be taught how to use his crutches
• C. A client with RA and a scheduled pain medication
• D. A client with a fractured ankle who would like a glass of water

Correct answer: A

Rationale:

4. The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?

• A. Tunnelling
• B. Eschar
• C. Blanching
• D. Cellulitis

Correct answer: B

Rationale:

5. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

• A. Creamy pus
• B. Serous
• C. Serosanguineous
• D. Purulent exudate

Correct answer: C

Rationale:

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