Nursing Elites

1. A client asks about the purpose of advance directives. Which of the following statements should the nurse make?

• A. They allow the court to overrule an adult client's refusal of medical treatment.
• B. They indicate the form of treatment a client is willing to accept in the event of a serious illness.
• C. They permit a client to withhold medical information from health care personnel.
• D. They allow health care personnel in the emergency department to stabilize a client's condition.

Correct answer: B

Rationale: The correct answer is B. Advance directives specify the type of medical treatment a client wishes to receive or avoid in the event of a serious illness. Choice A is incorrect because advance directives do not allow the court to overrule a client's refusal of medical treatment; they empower the client to make their own healthcare decisions. Choice C is incorrect because advance directives do not permit a client to withhold medical information; they provide guidance on the client's treatment preferences. Choice D is incorrect because advance directives do not specifically address the actions of health care personnel in the emergency department; they focus on the client's treatment preferences in general.

2. During passive range of motion (ROM) exercises, how should the nurse perform each movement for a patient with impaired mobility?

• A. The nurse moves each movement just to the point of resistance.
• B. The patient repeats each movement 5 times.
• C. The movement continues until the patient reports pain.
• D. The nurse completes each movement quickly and smoothly.

Correct answer: A

Rationale: During passive range of motion (ROM) exercises, the nurse is responsible for moving the patient's joints through their range of motion. The correct technique involves performing movements slowly and smoothly, only going to the point of resistance without causing pain. This technique helps maintain joint flexibility and prevent contractures. Choice A is the correct answer as it reflects the appropriate technique for passive ROM exercises. Choices B and C are incorrect because the patient is not actively participating, and ROM exercises should not cause pain. Choice D is incorrect as movements should be done deliberately and not quickly.

3. What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?

• A. Apply a condom catheter.
• B. Apply a skin protectant.
• C. Encourage increased fluid intake.
• D. Assess for bladder distention.

Correct answer: D

Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.

4. A healthcare professional is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)

• A. 400 mL/hr
• B. 200 mL/hr
• C. 300 mL/hr
• D. 250 mL/hr

Correct answer: A

Rationale: To administer 100 mL over 15 min, the IV pump should be set to deliver 400 mL/hr. This calculation is based on the concept that if 100 mL is given in 15 minutes, to find out how many milliliters are given in an hour, you would multiply by 4 (since 15 minutes is a quarter of an hour). Therefore, 100 mL x 4 = 400 mL per hour. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate required to administer 100 mL over 15 minutes.

5. A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?

• A. The statement of client rights and the client self-determination act
• B. Orders written by the healthcare provider
• C. A notarized original of advance directives brought in by the partner
• D. The clinical pathway protocol of the agency and the emergency department

Correct answer: C

Rationale: In this scenario, when the client is unconscious and unable to make decisions, a notarized original of advance directives brought in by the partner should be given priority to guide the direction of care. Advance directives provide legal documentation of the client's wishes regarding healthcare decisions in situations where they cannot express their preferences. The statement of client rights and the client self-determination act (Choice A) outlines general principles but does not provide specific guidance on the client's care. Orders written by the healthcare provider (Choice B) are important but may not reflect the client's preferences. Clinical pathway protocols (Choice D) are useful for standard care pathways but do not address individual client wishes.

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