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. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks how this can happen. What is the best response by the nurse?

• A. . "The fascia expands with injury, causing pressure on underlying nerves and muscles."?
• B. "An injured artery causes impaired arterial perfusion through the compartment."?
• C. "Bleeding and swelling cause increased pressure in an area that cannot expand."?
• D. . "A bone fragment has injured the nerve supply in the area."?

Correct answer: C

Rationale:

3. A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?

• A. Inquire about the frequency, quality and location of the pain
• B. Get the client pain medication
• C. Ensure the client knows he will have negative effects from immobility
• D. Review the client’s medication administration record

Correct answer: A

Rationale: Assessing the pain characteristics helps in managing the client’s pain effectively.

4. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?

• A. Encouraging bedrest
• B. Applying antiembolism stockings
• C. Tell the client to take anticoagulants
• D. Teaching about smoking cessation

Correct answer: B

Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.

5. 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:

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