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. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

• A. Creamy pus
• B. Serous
• C. Serosanguineous
• D. Purulent exudate

Correct answer: C

Rationale:

3. The following client come to the ophthalmology clinic. Which client needs to be seen first?

• A. Client who had recent cataract surgery and has worsening vision
• B. Client with an absent red reflex on ophthalmic examination
• C. Client with an intraocular pressure of 24 mm Hg
• D. Client with a tearing, reddened eye with exudate

Correct answer: A

Rationale: Worsening vision after cataract surgery requires immediate attention to prevent complications.

4. The nurse is caring for 4 clients. Which of these clients will the nurse see first?

• A. A client with sudden and increasing pain in his fractured arm
• B. A client being discharged in 2 hours and needs to be taught how to use his crutches
• C. A client with RA and a scheduled pain medication
• D. A client with a fractured ankle who would like a glass of water

Correct answer: A

Rationale:

5. Which finding is not typically associated with inflammation in a client?

• A. Pain
• B. Heat
• C. Polyuria
• D. Erythema

Correct answer: C

Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.

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