Nursing Elites

1. 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:

2. The client had surgery one day ago. What assessment is most likely related to pain?

• A. Blood pressure of 175/90 mm Hg
• B. Respirations of 10 breaths per minute
• C. Heart rate 60 beats/minute
• D. Oxygen saturation of 97%

Correct answer: A

Rationale:

3. What is a sign of inadequate perfusion?

• A. Intact sensation
• B. Pallor in toes
• C. Bounding pulses
• D. Pink fingers

Correct answer: B

Rationale:

4. What is the nurse's priority action for a client with compromised immunity?

• A. Wash hands before entering the client's room
• B. Take the client's vital signs every 4 hours
• C. Determine whether it is temporary or permanent
• D. Teach the family members to receive the flu shot annually

Correct answer: A

Rationale:

5. What is a negative effect of immobility on the cardiovascular system?

• A. Increased high density lipoprotein
• B. Increased circulation
• C. Increased pumping action of the heart
• D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.

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