Nursing Elites

1. Where will the nurse collect the most reliable source of pain assessment?

• A. From the nurse-to-nurse bedside report
• B. From a medical surgical book
• C. From the client
• D. From the client's chart

Correct answer: C

Rationale:

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. 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:

4. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?

• A. Deeply palpate the area for rebound tenderness
• B. Medicate the client for pain and reassess in 60 minutes
• C. Percuss over the area for a change in tone
• D. Compare the circumference to the left calf

Correct answer: D

Rationale:

5. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

• A. The nurse assesses capillary refill of 2 seconds
• B. The nurse cannot insert one finger between the cast and the skin
• C. The nurse finds 2+ pulses distal from the cast
• D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

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