Nursing Elites

1. Which among the following is NOT the cause of pressure ulcers?

• A. Immobility
• B. Poor nutrition
• C. Moisture
• D. Adequate perfusion

Correct answer: D

Rationale:

2. On inspection, which client does the nurse suspect of having a visual impairment?

• A. The client whose sclera is white
• B. The client who has an intact blink reflex
• C. The client who is tilting their head
• D. The client with equal pupils

Correct answer: C

Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.

3. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

• A. Assist the client to orthopneic position
• B. Offer a protein-rich diet
• C. Offer the client a bedpan for toileting
• D. Turn the client every 4 hours

Correct answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

4. A client has a new diagnosis of human immunodeficiency virus HIV. The client is distraught and does not know what to do. What intervention by the nurse is the best?

• A. Offer to tell the family for the client
• B. Call the hospital clergy to speak with the client
• C. Assess the client's support system
• D. Explain the legal requirements to tell sex partners

Correct answer: C

Rationale:

5. What is the nurse's priority action for a client with compromised immunity?

• A. Wash hands before entering the client's room
• B. Take the client's vital signs every 4 hours
• C. Determine whether it is temporary or permanent
• D. Teach the family members to receive the flu shot annually

Correct answer: A

Rationale:

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