Nursing Elites

1. 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:

2. What is a sign of inadequate perfusion?

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

Correct answer: B

Rationale:

3. On inspection, which client does the nurse suspect of having a visual impairment?

• A. The client whose sclera is white
• B. The client who has an intact blink reflex
• C. The client who is tilting their head
• D. The client with equal pupils

Correct answer: C

Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.

4. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

• A. Two-point gait
• B. Three-point gait
• C. Four-point gait
• D. Unaffected gait

Correct answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.

5. A nurse is caring for an intubated and sedated geriatric client. What intervention is most appropriate for reducing the risk for a friction and shear injury?

• A. Use a mechanical lift to reposition the client every 2 hours
• B. Elevate the client's head of the bed to 45 degrees
• C. Postpone daily bed bath
• D. Caregiver independently slides the client up in the bed

Correct answer: A

Rationale:

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