Nursing Elites

1. Which assessment is NOT a nonverbal sing of pain?

• A. Decreased attention span
• B. Grimacing
• C. Increase in heart rate
• D. Reported pain of 5/10

Correct answer: D

Rationale:

2. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?

• A. The client's incision site has eviscerated
• B. The client's incision site has lacerated
• C. The client's incisional site is approximated
• D. The client's incisional site has dehisced after.

Correct answer: A

Rationale:

3. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?

• A. Amount
• B. Consistency
• C. Heat
• D. Odor

Correct answer: C

Rationale:

4. A client has a new arm cast. What is incorrect teaching by the nurse?

• A. Use a sling to alleviate fatigue
• B. Elevate the arm above the heart to reduce swelling
• C. Report ‘hot spots’ felt under the cast
• D. Sudden increase in drainage is expected

Correct answer: D

Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.

5. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?

• A. The UAP puts shoes on the client
• B. The UAP removes floor rugs and loose objects from the path
• C. The UAP walks to the side and slightly in front of the client
• D. The UAP uses a transfer (gait) belt

Correct answer: C

Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.

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