Nursing Elites

1. 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:

2.

• A. Hyperthermia
• B. A cold environment
• C. Normal
• D. Hypothermia

Correct answer: A

Rationale:

3. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?

• A. The client sets the cap down in a manner that does not contaminate it.
• B. The client drops the prescribed number of drops into the conjunctival sac
• C. The client washes their hands before instilling the drops
• D. The client ensures that they touch the administration dropper to the eye

Correct answer: D

Rationale: Touching the dropper to the eye contaminates it and can lead to infection.

4. The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?

• A. 15 degrees
• B. 0 degrees
• C. 90 degrees
• D. 30 degrees

Correct answer: C

Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.

5. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

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