Nursing Elites

1. A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?

• A. Apply the stockings with the creases on the front of the leg.
• B. Apply the stockings while the client's legs are in a dependent position.
• C. Remove the stockings at least once per shift.
• D. Remove the stockings while the client is sitting in a reclining chair.

Correct answer: C

Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.

2. During passive range of motion (ROM) and splinting, the absence of which finding will indicate goal achievement for these interventions?

• A. Atelectasis
• B. Renal calculi
• C. Pressure ulcers
• D. Joint contractures

Correct answer: D

Rationale: The correct answer is D: Joint contractures. When a healthcare provider performs passive ROM and splinting on a patient, the goal is to prevent joint contractures. Joint contractures result from immobility and can lead to permanent stiffness and decreased range of motion. Atelectasis (choice A) is a condition where there is a complete or partial collapse of the lung, commonly due to immobility, but not directly related to passive ROM or splinting. Renal calculi (choice B) are kidney stones and are not typically associated with ROM exercises. Pressure ulcers (choice C) result from prolonged pressure on the skin and are prevented by repositioning the patient, not specifically addressed by ROM and splinting exercises.

3. A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client’s abdomen, the nurse expects the bowel sounds to be:

• A. Absent
• B. Hyperactive
• C. Normal
• D. Hypoactive

Correct answer: A

Rationale: In paralytic ileus, bowel sounds are typically absent or significantly reduced due to decreased motility of the intestines. This absence of bowel sounds is a key characteristic used in diagnosing paralytic ileus. Hyperactive bowel sounds are not expected in this condition as there is a lack of normal peristalsis. Normal bowel sounds would not be present in paralytic ileus, and hypoactive bowel sounds, which indicate decreased bowel motility, are more commonly associated with conditions like postoperative ileus or constipation, rather than paralytic ileus.

4. The nurse is caring for a client with cirrhosis of the liver. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Yellowing of the skin and eyes
• B. Dark-colored urine
• C. Abdominal distention
• D. Confusion

Correct answer: A

Rationale: Yellowing of the skin and eyes (jaundice) is a classic sign of liver dysfunction in clients with cirrhosis. Jaundice indicates the accumulation of bilirubin in the body due to impaired liver function. This finding suggests worsening liver damage and should be reported immediately to the healthcare provider for prompt evaluation and management. Dark-colored urine (choice B) is also a concerning symptom in liver disease, indicating possible bilirubin presence, but it is not as urgent as jaundice. Abdominal distention (choice C) and confusion (choice D) are common in cirrhosis but do not indicate an immediate need for healthcare provider notification compared to jajsondice.

5. A healthcare professional is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the professional assess for?

• A. Loss of bone mass
• B. Loss of strength
• C. Loss of weight
• D. Loss of hope

Correct answer: D

Rationale: Correct. Loss of hope is a significant psychosocial aspect that healthcare professionals should assess for in patients who are immobile. Immobility can lead to feelings of hopelessness and depression, impacting the patient's mental well-being. Assessing for loss of hope allows healthcare professionals to provide appropriate support and interventions to address the patient's emotional needs. Choices A, B, and C are incorrect because they primarily relate to physical changes (bone mass, strength, weight) rather than the psychosocial aspect of hope.

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