Nursing Elites

1. A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?

• A. Traumatic injury
• B. Pressure injury
• C. Friction injury
• D. Shearing injury

Correct answer: D

Rationale:

2. A nurse assesses an area of skin over a bony prominence. What finding would be most concerning?

• A. Redness
• B. Non-blanching
• C. Blanching
• D. Warmth

Correct answer: A

Rationale:

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. A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal?

• A. Assist the client to orthopneic position
• B. Offer the client a bedpan for toileting
• C. Offer a protein-rich diet
• D. Turn the client every 2 hours

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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