Nursing Elites

1. During a neurologic examination, which assessment should a nurse perform to test a client's balance?

• A. Romberg test
• B. Heel-to-toe walk
• C. Snellen test
• D. Spinal accessory function

Correct answer: A

Rationale: The Romberg test is used to assess a client's balance by evaluating their ability to maintain a steady posture with eyes closed. The heel-to-toe walk is another assessment that tests balance by assessing gait and coordination. The Snellen test is used to assess visual acuity and is unrelated to balance. Testing spinal accessory function involves assessing the movement of the head and shoulders and is not directly related to balance assessment.

2. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse’s priority?

• A. Teaching the client about the purpose of the medication
• B. Giving the medication at the administration time the provider prescribed
• C. Identifying the client’s medication allergies
• D. Documenting the client’s anxiety level

Correct answer: C

Rationale: The correct answer is C: Identifying the client's medication allergies. This is the priority action before administering any medication to prevent allergic reactions or adverse effects. Teaching the client about the medication's purpose is important for client understanding but not as critical as ensuring the absence of allergies. While giving medication at the prescribed time is crucial, verifying allergies takes precedence to ensure patient safety. Documenting the client's anxiety level is relevant for holistic care but is not the priority compared to ensuring safe medication administration.

3. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes, the client was told by the family member to turn to the right side. What is the appropriate comment for the nurse to make?

• A. Why don’t we now have the client turn back to the left side?
• B. That was done correctly. Did you have any problems with the insertion?
• C. Let’s check to see if the suppository is in far enough.
• D. Did you feel any stool in the intestinal tract?

Correct answer: B

Rationale: Choice B is the correct answer because the family member's actions in administering the rectal suppository were correct. Providing positive feedback and asking if there were any problems with the insertion is an appropriate response. Choice A is incorrect because there is no need to have the client turn back to the left side after the suppository has been administered. Choice C is incorrect as there is no indication that the suppository was not inserted correctly, so there is no need to check if it is in far enough. Choice D is incorrect because feeling stool in the intestinal tract is not relevant to the administration of a rectal suppository.

4. The nurse is admitting a patient diagnosed with a stroke. The healthcare provider writes orders for 'ROM as needed.' What should the nurse do next?

• A. Restrict the patient's mobility as much as possible.
• B. Realize the patient is unable to move extremities.
• C. Move all the patient's extremities.
• D. Further assess the patient.

Correct answer: D

Rationale: The correct answer is to further assess the patient. 'ROM as needed' stands for Range of Motion, indicating that the patient should have their limbs moved to maintain joint flexibility and muscle strength. Before initiating any movements, it is crucial to assess the patient's current condition to determine their abilities and limitations. Restricting mobility (choice A) is not appropriate as it contradicts the purpose of ROM exercises. Realizing the patient is unable to move extremities (choice B) assumes without assessment and can lead to inappropriate care. Moving all the patient's extremities (choice C) without assessing the patient first can be harmful, as it may cause pain or injury if done incorrectly. Therefore, further assessment is necessary to provide safe and effective care.

5. While administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

• A. Have the client hold their breath briefly and bear down.
• B. Clamp the enema tubing.
• C. Remind the client that cramping is common at this time.
• D. Raise the level of the enema fluid container.

Correct answer: C

Rationale: When a client reports abdominal cramping during a cleansing enema, it is important for the nurse to reassure the client that cramping is a common side effect. This reassurance helps the client understand that the cramping is normal and may subside once the enema is completed. Instructing the client to hold their breath and bear down (Choice A) is not appropriate and may cause discomfort. Clamping the enema tubing (Choice B) is unnecessary and could lead to complications. Raising the level of the enema fluid container (Choice D) does not address the client's discomfort due to cramping. Therefore, the most suitable action is to provide reassurance to the client about the common occurrence of cramping during the enema.

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