Nursing Elites

1. 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.

2. The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?

• A. "My grandfather always had problems with his arthritis, and he would tell me that it is better to be more stoic and not let pain interrupt your life"?
• B. "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."?
• C. "Place throw rugs throughout your home. You will enjoy how pretty they are, and you can use them to cover up power cords, so you do not trip on them."?
• D. "Lack of home safety may be an issue of compliance. Are you being compliant with your medication?"?

Correct answer: B

Rationale: The correct answer is B. This statement is the most appropriate because it focuses on providing practical solutions to enhance the client's safety at home while managing rheumatoid arthritis. Adaptive devices like grab bars, reaching tools, grasping devices, and adaptive silverware can help the client maintain independence and prevent accidents. Choice A is incorrect as it does not provide practical advice on home safety but rather a personal anecdote. Choice C is incorrect as throw rugs can pose a tripping hazard instead of enhancing safety. Choice D is also incorrect as it does not directly address home safety measures but rather shifts the focus to medication compliance.

3. A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?

• A. Traumatic injury
• B. Pressure injury
• C. Friction injury
• D. Shearing injury

Correct answer: D

Rationale:

4. Why is a client with osteoporosis prone to fractures?

• A. The client has bone spurs that lead to fractures
• B. The client has increased bone density
• C. The client has porous bones
• D. The client is not prone to fractures

Correct answer: C

Rationale: The correct answer is C. Osteoporosis is characterized by porous, weak bones due to decreased bone density. This porous nature of bones in osteoporosis makes them more prone to fractures. Choice A is incorrect because bone spurs do not lead to fractures in osteoporosis; they are bony outgrowths unrelated to osteoporosis. Choice B is incorrect as osteoporosis is associated with decreased, not increased, bone density. Choice D is incorrect as individuals with osteoporosis are indeed prone to fractures due to weakened bones.

5. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?

• A. Send the client back to surgery
• B. Assess the wound for signs of dehiscence
• C. Call the provider immediately
• D. Prepare to culture the wound

Correct answer: B

Rationale:

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