Nursing Elites

1. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

• A. Remove the nursing diagnosis in the plan of care since it has not occurred
• B. Change the nursing diagnosis in plan of care to impaired mobility
• C. Modify the nursing diagnosis in plan of care to impaired skin integrity
• D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present

Correct answer: D

Rationale:

2. A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him up in bed. What force caused the injury?

• A. Shearing or friction
• B. Twisting and bending
• C. Pressure or gravity
• D. Chemical or pressure

Correct answer: A

Rationale:

3. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

• A. Administer antibiotics to the client
• B. Increase the client's protein intake
• C. Teach relaxation breathing to reduce the client's pain
• D. Provide the client with anti-pyretic therapy

Correct answer: A

Rationale:

4. A nurse assesses an audible grating sound (Crepitus) when a client with osteoarthritis moves his knees. What is the cause of this sound?

• A. A herniated disk in the diseased joint
• B. Pieces of bone and cartilage floating
• C. Popping bursae from standing
• D. Years of an autoimmune process

Correct answer: A

Rationale:

5. A nurse working in an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at highest risk for skin breakdown?

• A. An adolescent who has a patella fracture and is in an immobilizer
• B. A young adult who has a femur fracture and is going to surgery in two hours
• C. A middle-aged adult who has fractured his radius and has a cast
• D. An older adult who has a hip fracture and is immobile

Correct answer: D

Rationale:

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