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. What are signs of hearing loss? (Select all that apply)

• A. Presence of cerumen
• B. Presence of cerumen
• C. Tinnitus
• D. Frequent asking of others to repeat statements

Correct answer: C

Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.

3. Which finding is not typically associated with inflammation in a client?

• A. Pain
• B. Heat
• C. Polyuria
• D. Erythema

Correct answer: C

Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.

4. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?

• A. Avoid contact sports until the infection has cleared
• B. Use a bath sponge to cleanse the skin
• C. Wash hands with soap and water before and after touching the infected area
• D. Use an antibacterial soap when showering

Correct answer: B

Rationale:

5. A nurse is caring for an immobile client. What is the priority assessment of this client?

• A. Palpate for edema
• B. Auscultate for bowel sounds
• C. Inspect the skin for injury
• D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

Similar Questions