Nursing Elites

1. 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:

2. The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?

• A. Offer the client protein with meals to promote healing
• B. Remove the old dressing with clean gloves
• C. Teach the client about nonpharmacological pain control methods
• D. Check medication administration record (MAR)for as needed orders (PRN)

Correct answer: C

Rationale:

3. A nurse assesses an audible grating sound (Crepitus) when a client with osteoarthritis moves his knees. What is the cause of this sound?

• A. A herniated disk in the diseased joint
• B. Pieces of bone and cartilage floating
• C. Popping bursae from standing
• D. Years of an autoimmune process

Correct answer: A

Rationale:

4. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

• A. The pain will go away after the swelling decreases.
• B. That is phantom limb pain.
• C. Your foot has been amputated, so you are not having pain in that foot.
• D. On a scale of 0-10, how would you rate your pain?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.

5. What is a sign of inadequate perfusion?

• A. Intact sensation
• B. Pallor in toes
• C. Bounding pulses
• D. Pink fingers

Correct answer: B

Rationale:

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