Nursing Elites

1. A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?

• A. Collect a culture of the purulent fluid
• B. Cleanse the skin around the pins
• C. Administer an antibiotic
• D. Instruct the client to complete exercise of the affected extremity

Correct answer: A

Rationale:

2. The nurse notices a new area of skin breakdown near the site of a dressing. This would be an example of which phase of the nursing process?

• A. Diagnosis
• B. Assessment
• C. Implementation
• D. Evaluation

Correct answer: B

Rationale:

3. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

• A. The nurse assesses capillary refill of 2 seconds
• B. The nurse cannot insert one finger between the cast and the skin
• C. The nurse finds 2+ pulses distal from the cast
• D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

4. 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. Intentional
• C. Using standard precautions
• D. Proliferative

Correct answer: C

Rationale:

5. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?

• A. Insert the wound and assess the drainage
• B. Apply topical ointment to the wound
• C. Call the provider to initiate antibiotics
• D. Culture the wound

Correct answer: D

Rationale:

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