Nursing Elites

1. A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?

• A. Inquire about the frequency, quality and location of the pain
• B. Get the client pain medication
• C. Ensure the client knows he will have negative effects from immobility
• D. Review the client’s medication administration record

Correct answer: A

Rationale: Assessing the pain characteristics helps in managing the client’s pain effectively.

2. What nursing interventions increase the risk the pressure injuries?

• A. Padding hard surfaces
• B. Have client sit in wheelchair as much as possible
• C. Place pillows between bony surfaces
• D. Keep head of bed (HOB) at or less than 3

Correct answer: B

Rationale:

3. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?

• A. The client's incision site has eviscerated
• B. The client's incision site has lacerated
• C. The client's incisional site is approximated
• D. The client's incisional site has dehisced after.

Correct answer: A

Rationale:

4. While completing a health history the client reports experiencing blurring of vision in both eyes without associated pain. What condition does the nurse suspect?

• A. Macular degeneration
• B. Cataract
• C. Retinal detachment
• D. Glaucoma

Correct answer: B

Rationale: Cataracts can cause blurring of vision in both eyes without associated pain.

5. A nurse is caring for an immobile client. What is the priority assessment of this client?

• A. Palpate for edema
• B. Auscultate for bowel sounds
• C. Inspect the skin for injury
• D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

Similar Questions