Nursing Elites

1. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks how this can happen. What is the best response by the nurse?

• A. . "The fascia expands with injury, causing pressure on underlying nerves and muscles."?
• B. "An injured artery causes impaired arterial perfusion through the compartment."?
• C. "Bleeding and swelling cause increased pressure in an area that cannot expand."?
• D. . "A bone fragment has injured the nerve supply in the area."?

Correct answer: C

Rationale:

2. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

• A. The client refused her pain medication this morning and is doing physical therapy.
• B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
• C. The client reports intermittent flatus and minor abdominal discomfort.
• D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.

3. 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.

4. Most adults with human immunodeficiency virus will exhibit which of the following laboratory values?

• A. Higher than normal number of CD4+ T-cells and CD8+ T-cells are normal
• B. Lower than normal number of CD4+ T-cells and higher than normal CD8+ T-cells
• C. Higher than normal number of CD4+ T-cells and CD8+ T-cells are low
• D. Lower than normal number of CD4+ T-cells and CD8+ T-cells are normal

Correct answer: D

Rationale:

5. 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:

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