Nursing Elites

1. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

• A. Stage III pressure injury
• B. A stage II pressure injury
• C. A non-staging pressure injury
• D. Stage IV pressure injury

Correct answer: D

Rationale:

2. What is an example of a client's primary defense to infection?

• A. Intact skin
• B. Inflammation
• C. Phagocytosis
• D. Fever

Correct answer: A

Rationale:

3. Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by health care workers?

• A. Wearing a mask within three feet of the client
• B. Using standard precautions
• C. Applying hand sanitizer to gloves during cares
• D. Double gloving

Correct answer: B

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. What is correct health promotion education for vision? (Select all that apply)

• A. Wear sunglasses to filter ultraviolet (UV) light
• B. Avoid nonsteroidal anti-inflammatory drug (NSAID) use
• C. Wash your hands before touching your eyelids
• D. All of The Above

Correct answer: D

Rationale: Wearing sunglasses, washing hands before touching eyelids, and wearing eye protection when working with fluids are important health promotion activities for vision.

Similar Questions