Nokea
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:
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A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis
carinii (PCP). What is the nurse's priority assessment for this client?
- A. Skin turgor
- B. Lung sounds
- C. Radial pulses
- D. Capillary refill
Correct Answer: B
Rationale:
A client who is sitting in High-Fowler's position is at risk for what type of
injury as the skin layers shift in opposite directions?
- A. Traumatic injury
- B. Pressure injury
- C. Friction injury
- D. Shearing injury
Correct Answer: D
Rationale:
The nurse has documented the following wound assessment. "Shallow, open,
reddened ulcer with no slough on the anterior region of the right heel?"? what
stage is the wound?
- A. Stage 3
- B. Stage 4
- C. Stage 1
- D. Stage 2
Correct Answer: D
Rationale:
The nurse is providing education to a client regarding the administration of eye
drops. Which of the following actions indicates the need for further client
education?
- A. The client instills the prescribed number of eye drops into the conjunctival sac
- B. The client sets the cap to the eye drop container down in a manner that does not
contaminate it - C. The client touches the administration dropper her to the eye
- D. The client washes her hands before instilling the eye drops
Correct Answer: C
Rationale:
A nurse is caring for a client who is post-operative following an open reduction
internal fixation (ORIF) of a femur fracture. What is NOT included in the evaluation
of the neurovascular status of the client's affected extremity?
- A. Color
- B. Temperature
- C. Sensation
- D. Skin integrity
Correct Answer: D
Rationale: