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 caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don?

• A. PAPR mask
• B. Sterile gloves
• C. Gown
• D. Surgical mask

Correct answer: C

Rationale:

3. The nurse is caring for 4 clients. What client should the nurse see first?

• A. A client with multiple children visiting
• B. A client with lupus asking for dinner
• C. A client on Methotrexate with a fever
• D. A client with chronic rheumatic pain

Correct answer: C

Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.

4. The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?

• A. Tunnelling
• B. Eschar
• C. Blanching
• D. Cellulitis

Correct answer: B

Rationale:

5. The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?

• A. Because it is easy to digest.'
• B. Protein has amin acid that promotes wound healing.'
• C. If you do not like it, you do not have to take it.'
• D. These supplements have nothing to do with your wound,'

Correct answer: B

Rationale:

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