Nursing Elites

1. A healthcare professional is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?

• A. Impulse control difficulty
• B. Poor judgement
• C. Inability to recognize familiar objects
• D. Loss of depth perception

Correct answer: C

Rationale: Patients who have experienced a left-hemispheric stroke may exhibit symptoms of agnosia, which is the inability to recognize familiar objects or people. This occurs due to damage to the right hemisphere of the brain, which is responsible for visual and spatial perception. Impulse control difficulty, poor judgment, and loss of depth perception are not typically associated with left-hemispheric strokes.

2. Which action would break sterile technique while preparing a sterile field for a dressing change?

• A. Using sterile forceps instead of sterile gloves to handle a sterile item
• B. Touching the outside wrapper of sterilized material without sterile gloves
• C. Placing a sterile object at the edge of the sterile field
• D. Pouring out a small amount of solution (15 to 30 ml) before pouring it into a sterile container

Correct answer: B

Rationale: Touching the outside wrapper of sterilized material without sterile gloves can introduce contaminants and compromise the sterility of the item. It is crucial to maintain strict adherence to sterile technique to prevent infections and ensure patient safety during procedures.

3. A client has had a cast applied, and a nurse is providing care. Which of the following actions should the nurse take first?

• A. Place an ice pack over the cast.
• B. Palpate the pulse distal to the cast.
• C. Teach the client to keep the cast clean and dry.
• D. Position the casted extremity on a pillow.

Correct answer: B

Rationale: When caring for a client with a newly applied cast, the nurse's priority should be to assess the circulation by palpating the pulse distal to the cast. This is crucial to ensure there is no compromise in blood flow, which could lead to serious complications. Placing an ice pack over the cast, teaching the client about cast care, and positioning the casted extremity on a pillow are important interventions but should follow the assessment of circulation.

4. After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client’s vital signs. What phase of the nursing process is being implemented by the nurse?

• A. Assessment
• B. Diagnosis
• C. Planning
• D. Implementation

Correct answer: A

Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process. Choice B, 'Diagnosis,' would involve analyzing the collected data to identify the client's health problems. Choice C, 'Planning,' would be developing a plan of care based on the assessment findings. Choice D, 'Implementation,' is the phase where the nurse carries out the plan of care developed during the planning phase.

5. When administering digoxin 0.125 mg PO to an adult client, for which of the following findings should the nurse report to the provider?

• A. Potassium level 4.2 mEq/L.
• B. Apical pulse 58/min
• C. Digoxin level 1 ng/mL
• D. Constipation for 2 days

Correct answer: C

Rationale: Monitoring the digoxin level is crucial as it helps determine the drug's effectiveness and potential toxicity. A digoxin level of 1 ng/mL is within the therapeutic range. However, levels above this range can lead to toxicity, causing adverse effects like nausea, vomiting, visual disturbances, and dysrhythmias. Therefore, the nurse should report a digoxin level of 1 ng/mL to the provider for further evaluation and potential dose adjustment.

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