Nursing Elites

1. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

2. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

• A. Administer antibiotics to the client
• B. Increase the client's protein intake
• C. Teach relaxation breathing to reduce the client's pain
• D. Provide the client with anti-pyretic therapy

Correct answer: A

Rationale:

3. A client arrives speaking only Spanish. What is the priority nursing intervention?

• A. Give the client a tour of the unit
• B. Verify the reason for admission
• C. Request a medical interpreter
• D. Call the chaplain for support

Correct answer: C

Rationale:

4. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?

• A. Assess the right radial pulse
• B. Call the provider
• C. Administer pain medication
• D. Assess the right pedal pulse

Correct answer: A

Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.

5. The nurse is preparing communication for a provider. The client is experiencing acute pain greater than the severity of the fracture. Distal to the injury, he is experiencing a 'pins and needles' sensation. The pulse is weak and thready but is bounding on all unaffected extremities. What emergent condition does the nurse suspect?

• A. Ischial tuberosity
• B. Compartment syndrome
• C. Broken arm syndrome
• D. Pulmonary embolism

Correct answer: B

Rationale:

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