Nursing Elites

1. 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.

2. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

• A. Client will increase mobility by the time of discharge from hospital
• B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
• C. Client will increase activity tolerance by discharge from the hospital
• D. Client will remain free from falls throughout their hospital stay

Correct answer: D

Rationale:

3. 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.

4. Which nonpharmacological intervention does not help reduce edema?

• A. Heat therapy
• B. Passive range of motion (PROM)
• C. Elevation of the extremity
• D. Cold therapy

Correct answer: A

Rationale: The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.

5. What is not a nursing intervention for a client with osteoporosis?

• A. Nurse will encourage the intake of adequate amounts of calcium and vitamin D
• B. Nurse will encourage the client to complete weight-bearing exercises
• C. Nurse will encourage the client to avoid muscle strengthening exercises
• D. Nurse will encourage the client to avoid repetitive movements

Correct answer: C

Rationale: The correct answer is C. Avoiding muscle strengthening exercises is not recommended for clients with osteoporosis; on the contrary, weight-bearing exercises are beneficial. Choice A is correct as ensuring adequate calcium and vitamin D intake is essential for bone health. Choice B is also correct as weight-bearing exercises help improve bone density. Choice D is incorrect because avoiding repetitive movements is not a standard nursing intervention for osteoporosis.

Similar Questions