Nursing Elites

1. The client with RA complains of intensely dry eyes. What does the nurse suspect?

• A. Systemic sclerosis
• B. Sjogren's syndrome
• C. Chron's disease
• D. Discoid lupus

Correct answer: B

Rationale:

2. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

• A. Stage III pressure injury
• B. A stage II pressure injury
• C. A non-staging pressure injury
• D. Stage IV pressure injury

Correct answer: D

Rationale:

3. What is a sign of inadequate perfusion?

• A. Intact sensation
• B. Pallor in toes
• C. Bounding pulses
• D. Pink fingers

Correct answer: B

Rationale:

4. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?

• A. Observe client for changes in mental status
• B. Use aseptic technique for wound care and emptying of drains
• C. Keep the client's heels off the bed
• D. Perform neurovascular assessments per protocol

Correct answer: D

Rationale:

5. The nurse is caring for 4 clients. Which of these clients will the nurse see first?

• A. A client with rheumatoid arthritis and a scheduled pain medication
• B. A client being discharged in 2 hours and needs to be taught how to use crutches
• C. A client with sudden and increasing pain in a fractured arm
• D. A client with a fractured ankle who would like a glass of water

Correct answer: C

Rationale: The correct answer is C because sudden and increasing pain in a fractured arm indicates a potential complication that requires immediate attention to assess and manage. Choices A, B, and D do not present immediate life-threatening situations or emergent needs compared to sudden and increasing pain in a fractured arm, which takes priority to ensure the client's safety and comfort.

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