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 the priority nursing diagnosis for a client with metastatic bone disease?

• A. Chronic pain
• B. Impaired mobility
• C. Risk for falls
• D. Risk for infection

Correct answer: C

Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.

3. The client complains of fatigue and joint pain and reports that they are unable to walk due to pain in the knees. What is the most appropriate statement by the nurse?

• A. "You just have arthritis and should take some ibuprofen."?
• B. "You should avoid walking. This might be osteoporosis."?
• C. "Please tell me more about when your pain started."?
• D. "You need to lose weight or the pain won't go away."?

Correct answer: C

Rationale:

4. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?

• A. Deliver upward abdominal thrusts with a fisted hand
• B. Perform a blind finger sweep of the child's mouth
• C. Complete five rapid back blows between the shoulder blades
• D. Encourage the child to continue coughing

Correct answer: D

Rationale:

5. What nursing interventions increase the risk the pressure injuries?

• A. Padding hard surfaces
• B. Have client sit in wheelchair as much as possible
• C. Place pillows between bony surfaces
• D. Keep head of bed (HOB) at or less than 3

Correct answer: B

Rationale:

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