Nursing Elites

1. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?

• A. The client reports chronic fatigue
• B. The client has a butterfly rash
• C. Blood pressure of 126/85 mm Hg
• D. Urine output of 20 mL/hour

Correct answer: D

Rationale:

2. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a 'pins and needles' sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect?

• A. Ischial tuberosity
• B. Compartment syndrome
• C. Broken arm syndrome
• D. Pulmonary embolism

Correct answer: B

Rationale:

3. What complication of wound healing is an abnormal passage that connects two body cavities or a cavity and the skin?

• A. Fistula
• B. Hemorrhage
• C. Evisceration
• D. infection

Correct answer: A

Rationale:

4. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?

• A. The UAP puts shoes on the client
• B. The UAP removes floor rugs and loose objects from the path
• C. The UAP walks to the side and slightly in front of the client
• D. The UAP uses a transfer (gait) belt

Correct answer: C

Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.

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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