Nursing Elites

1. 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.

2. An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?

• A. Help the client write down the questions to ask the provider, so that the client doesn’t forget
• B. Reassure the client that everything will be explained
• C. Explain the procedure in detail yourself
• D. Direct the client to search for information online

Correct answer: A

Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.

3. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

• A. Ask another nurse to observe the medication wastage
• B. Notify the pharmacy when wasting the medication
• C. Lock the remaining medication in the controlled substance cabinet
• D. Dispose of the vial with the remaining medication in a sharps container

Correct answer: A

Rationale: In medication wastage situations involving controlled substances, it is crucial to have a second nurse observe and verify the disposal process. This practice ensures accountability and prevents any mishandling or diversion of the medication. Choice B is incorrect because notifying the pharmacy is not the immediate action required in this scenario. Choice C is incorrect as locking the remaining medication in the controlled substance cabinet without proper witnessing does not ensure accountability. Choice D is incorrect as disposing of the vial with the remaining medication in a sharps container does not address the need for a witness to verify the wastage of the controlled substance.

4. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client’s record first?

• A. Assessment
• B. History of present illness
• C. Plan of care
• D. Admission date and time

Correct answer: D

Rationale: When admitting a client to a medical-surgical unit, documenting the admission date and time is crucial as it establishes the timeline for the client's care. This information ensures accurate tracking of interventions and facilitates communication among the healthcare team. While assessment, history of present illness, and plan of care are important components of the admission process, documenting the admission date and time takes priority to establish a baseline for care delivery. Without the admission date and time, the continuity of care and coordination among healthcare providers may be compromised.

5. The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run over 4 hours for a client who has just delivered a 10-pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The LPN/LVN plans to set the flow rate at how many gtt/min?

• A. 42 gtt/min
• B. 83 gtt/min
• C. 125 gtt/min
• D. 250 gtt/min

Correct answer: B

Rationale: To calculate the flow rate in drops per minute (gtt/min), the formula is Total volume (mL) ÷ Time (min) ÷ Drop factor (gtt/mL). In this case, 1000 mL ÷ 240 min ÷ 20 gtt/mL = 83 gtt/min. Therefore, setting the flow rate to 83 gtt/min ensures the correct administration of the IV fluids and medication. Choices A, C, and D are incorrect as they do not align with the correct calculation based on the provided information.

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