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 activities should the client avoid after cataract surgery? (Select all that apply)

• A. Blowing one’s nose
• B. Bearing down during defecation
• C. Lifting items heavier than 10 pounds
• D. All of the Above

Correct answer: D

Rationale: After cataract surgery, the client should avoid activities that can increase intraocular pressure. Blowing one’s nose and bearing down during defecation can raise the pressure inside the eye, which can be harmful during the healing process. Lifting items heavier than 10 pounds can also lead to an increase in intraocular pressure. Therefore, all the activities mentioned in the choices (nose blowing, bearing down during defecation, and lifting heavy items) should be avoided after cataract surgery to promote proper healing and reduce the risk of complications.

3. What phase of wound healing occurs at the time of injury and lasts about 3-5 days?

• A. Maturation
• B. Intentional
• C. Inflammatory
• D. Proliferative

Correct answer: C

Rationale:

4. Which of the following lab tests should NOT be used for diagnosing connective tissue diseases?

• A. Rheumatoid factor (RF)
• B. Erythrocyte sedimentation rate (ESR)
• C. Anti-nuclear antibody (ANA)
• D. Thyroid stimulating hormone (TSH)

Correct answer: D

Rationale:

5. What should be done immediately after an ankle injury?

• A. Immobilize, heat, compress, and elevate the ankle
• B. Rest, ice, compress, and lower the ankle
• C. Rest, ice, compress, and elevate the ankle
• D. Rest, incubate, confine, and lower the ankle

Correct answer: C

Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.

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