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. The client has been asked to perform weight-bearing exercises three times a week. The client admits to not doing the recommended exercises. What is the most appropriate response by the nurse?

• A. I walk 3 miles every day. Would you like to join me?
• B. Tell me more about your experience with these exercises.
• C. My dad never exercised. He fell and broke his hip. Is that your goal?
• D. You should be doing these exercises.

Correct answer: B

Rationale: The most appropriate response by the nurse is to ask the client to elaborate on their experience with the exercises. By doing so, the nurse can gain insight into any barriers the client may be facing and work together to find solutions to improve adherence. Choice A is not appropriate as it doesn't address the client's situation. Choice C is not relevant and may induce fear in the client. Choice D is directive and does not promote open communication or understanding of the client's perspective.

3. What is the best goal for pain control in a client with RA?

• A. The client will eat healthy meals today and stay hydrated
• B. The client will have throughout the entire day
• C. The client will have pain less than 3/10 for most of the day
• D. The client will have pain less than 8/10 throughout the day

Correct answer: D

Rationale:

4. The nurse uses proper body mechanics to move a client up in bed. What action by the nurse will increase their risk of a workplace injury?

• A. Place the bed in the lowest possible position
• B. Use the legs when lifting
• C. Keep feet apart to provide a wide base of support
• D. Face the direction of the movement

Correct answer: A

Rationale: Placing the bed in the lowest possible position increases the risk of injury because it does not support proper body mechanics. When lifting a client, it is important to have the bed at a comfortable height to avoid strain. Using the legs when lifting (choice B) is correct as it reduces the strain on the back. Keeping feet apart to provide a wide base of support (choice C) helps with stability and balance. Facing the direction of the movement (choice D) is essential for maintaining proper alignment and reducing the risk of injury.

5. What health teaching would not help an older adult avoid a musculoskeletal injury?

• A. Avoid home modification
• B. Wear a helmet when riding a bicycle
• C. Osteoporosis screening
• D. Fall prevention

Correct answer: A

Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.

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