Nursing Elites

1. A client is undergoing range of motion exercises, and the nurse moves the leg in a pattern of circumduction. Which movement is the nurse performing?

• A. Bending the leg at the knee
• B. Turning the foot inward and outward
• C. Moving the leg in a circle
• D. Moving the leg forward and up

Correct answer: C

Rationale: Circumduction involves moving a limb in a circular pattern. In this scenario, the nurse is performing circumduction by moving the leg in a circular motion, engaging the muscles of the gluteus maximus and gluteus medius. Choice A, 'Bending the leg at the knee,' is incorrect as it describes flexion and extension movements. Choice B, 'Turning the foot inward and outward,' refers to inversion and eversion movements of the foot, not circumduction. Choice D, 'Moving the leg forward and up,' describes flexion and abduction movements, not circumduction.

2. The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?

• A. Document the seizure
• B. Perform neurologic checks
• C. Take the patient's vital signs
• D. Restrain the patient for protection

Correct answer: C

Rationale: After a patient with migraine headaches has a seizure, it is important to assess their vital signs to monitor their condition. This task can be safely delegated to a nursing assistant as it falls within their scope of practice. Documenting the seizure and performing neurologic checks require a higher level of training and should be done by a nurse or healthcare provider. Restraint should never be used as a first-line intervention after a seizure unless there is an immediate threat to the patient's safety, and it should be done following proper protocols and with appropriate training.

3. The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene?

• A. Percussing twice over each area
• B. Striking with the fingertip, not the finger pad
• C. Using the wrist to make the strikes, not the arm
• D. Quickly lifting the striking finger after each stroke

Correct answer: A

Rationale: The correct answer is to percuss twice over each area, not once. This technique helps ensure a more accurate assessment. Striking with the fingertip instead of the finger pad is correct because the tip of the finger produces clearer sounds. Using the wrist to make the strikes instead of the arm is appropriate as it allows for more controlled and precise percussion. Quickly lifting the striking finger after each stroke is also correct to prevent damping off vibrations. Therefore, percussing once over each area (Choice A) is incorrect as it does not follow the standard percussion technique.

4. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?

• A. 240 cc
• B. 120 cc
• C. 8 cc
• D. 0 cc because Italian ice is not a fluid

Correct answer: A

Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.

5. The nurse is assessing the vital signs of a 20-year-old marathon runner and documents the following vital signs: temperature"?36�C; pulse"?48 beats per minute; respirations"?14 breaths per minute; blood pressure"?104/68 mm Hg. Which statement is true concerning these results?

• A. The patient is experiencing bradycardia.
• B. These are normal vital signs for a healthy, athletic adult.
• C. The patient's pulse rate is not normal"?no action is required.
• D. The patient's next clinic visit should occur as scheduled.

Correct answer: B

Rationale: The correct answer is, 'These are normal vital signs for a healthy, athletic adult.' A pulse rate of 48 beats per minute is considered bradycardia in adults, but it is not a concern in well-trained athletes like marathon runners. Bradycardia is a normal physiological response to aerobic conditioning. Tachycardia, on the other hand, is defined as a pulse rate above 100 beats per minute, which is not the case here. The low pulse rate in this scenario is a reflection of the athlete's cardiovascular fitness. Therefore, there is no need to notify the physician or schedule a follow-up visit based on these findings.

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