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 nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate?

• A. Droplet
• B. Contact
• C. Airborne
• D. Protective

Correct answer: C

Rationale:

3. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

• A. Assist the client to orthopneic position
• B. Offer a protein-rich diet
• C. Offer the client a bedpan for toileting
• D. Turn the client every 4 hours

Correct answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

4. Which client is at highest risk of compromised immunity?

• A. A client who just had surgery
• B. A client who just delivered a baby
• C. A client with extreme anxiety
• D. A client who is awaiting surgery

Correct answer: A

Rationale:

5. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?

• A. The client reports chronic fatigue
• B. The client has a butterfly rash
• C. Blood pressure of 126/85 mm Hg
• D. Urine output of 20 mL/hour

Correct answer: D

Rationale:

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