Nursing Elites

1. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?

• A. Amputation
• B. Deep vein thrombosis
• C. Internal bleeding
• D. Kidney failure

Correct answer: B

Rationale:

2. A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?

• A. The client is in a private room.
• B. The client has a vase of fresh flowers on the table
• C. The client has a dedicated vital signs machine
• D. There is hand sanitizer by the door

Correct answer: B

Rationale:

3. A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?

• A. Skin turgor
• B. Lung sounds
• C. Radial pulses
• D. Capillary refill

Correct answer: B

Rationale:

4. Which of the following statements by a client with human immunodeficiency virus (HIV) does NOT requires further teaching?

• A. I can spread this through contact with surfaces, so I need to wear gloves in public.'
• B. Because I have HIV, that means I'm an AIDS patient'
• C. I need to ensure that I place my needles in a proper needle disposal container.'
• D. I can still have unprotected intercourse with my partner since he does not have HIV.'

Correct answer: C

Rationale:

5. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

• A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
• B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
• C. The UAP carefully empties the indwelling catheter bag
• D. The UAP shows the client how to use the call light

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.

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