Nursing Elites

1. Where will the nurse collect the most reliable source of pain assessment?

• A. From the nurse-to-nurse bedside report
• B. From a medical surgical book
• C. From the client
• D. From the client's chart

Correct answer: C

Rationale:

2. What is the priority nursing diagnosis after surgery to repair a fracture?

• A. Disturbed body image
• B. Risk for infection
• C. Risk for impaired skin integrity
• D. Acute pain

Correct answer: B

Rationale: The correct answer is B: Risk for infection. After surgery to repair a fracture, the priority nursing diagnosis is to monitor for the risk of infection to promote proper healing. Infections can significantly delay the healing process and lead to further complications. Choices A, C, and D are not the priority immediately post-surgery. Disturbed body image, risk for impaired skin integrity, and acute pain may be concerns but are not the priority in the immediate post-operative period following fracture repair.

3. The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?

• A. "Ice packs can be used to reduce swelling but should be removed after 20 minutes."?
• B. "Heat always makes the swelling go down. You do not need any other interventions."?
• C. "Try high impact exercise exercise like running to loosen up your joints and reduce pain."?
• D. "Apply ice packs. It is generally okay to keep them on for up to one hour at a time."?

Correct answer: A

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. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

• A. The nurse assesses capillary refill of 2 seconds
• B. The nurse cannot insert one finger between the cast and the skin
• C. The nurse finds 2+ pulses distal from the cast
• D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

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