Nursing Elites

1. Which of the following statements by a client with human immunodeficiency virus (HIV) does NOT requires further teaching?

• A. I can spread this through contact with surfaces, so I need to wear gloves in public.'
• B. Because I have HIV, that means I'm an AIDS patient'
• C. I need to ensure that I place my needles in a proper needle disposal container.'
• D. I can still have unprotected intercourse with my partner since he does not have HIV.'

Correct answer: C

Rationale:

2. 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.

3. The nurse Is teaching the client how to administer eye drops. Which of these actions indicates the need for further client education?

• A. The client sets the cap down in a manner that does not contaminate it.
• B. The client drops the prescribed number of drops into the conjunctival sac
• C. The client washes their hands before instilling the drops
• D. The client ensures that they touch the administration dropper to the eye

Correct answer: D

Rationale: Touching the dropper to the eye contaminates it and can lead to infection.

4. The nurse is most concerned about which of these findings in a client with systemic lupus erythematous?

• A. The client reports chronic fatigue
• B. The client has a butterfly rash
• C. Blood pressure of 126/85 mm Hg
• D. Urine output of 20 mL/hour

Correct answer: D

Rationale:

5. Dry skin (Xerosis) can lead to itching (Pruritis). What statement by the client indicates need for further teaching about preventing dry skin?

• A. I will drink at least 3000 mL of water daily."?
• B. . 'I will shower every day in hot water."?
• C. I will avoid tights belts."?
• D. I will use a humidifier during the winter months."?

Correct answer: B

Rationale:

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