Nokea
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:
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Which finding is not typically associated with inflammation in a client?
- A. Pain
- B. Heat
- C. Polyuria
- D. Erythema
Correct Answer: C
Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.
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:
A man has been admitted to the hospital unit with a medical diagnosis of
COPD. He is receiving supplemental oxygen at 2 L/min via nasal cannula.
Which positioning technique will best assist him with his breathing?
- A. Prone position
- B. Sim's position
- C. Lateral position
- D. Fowler's position
Correct Answer: D
Rationale:
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:
The nurse assesses a deep wound. The area is covered by black and necrotic
tissue. What term would the nurse use when documenting this wound?
- A. Tunnelling
- B. Eschar
- C. Blanching
- D. Cellulitis
Correct Answer: B
Rationale: