Nursing Elites

1. 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.

2. What is the most important action for the LPN/LVN to take to prevent infection in a client with an indwelling urinary catheter?

• A. Ensure the catheter tubing is free of kinks.
• B. Change the catheter every 72 hours.
• C. Clean the perineal area with an antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: A

Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This step helps prevent obstruction in the tubing, maintaining proper urine flow and reducing the risk of infection. Changing the catheter every 72 hours is not recommended unless clinically indicated, as routine changes can increase the risk of introducing pathogens. Cleaning the perineal area with an antiseptic solution is essential for general hygiene but does not directly prevent catheter-related infections. Irrigating the catheter with normal saline every shift is not a standard practice and can introduce microorganisms into the urinary tract, increasing the risk of infection.

3. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?

• A. Spaghetti
• B. Watermelon
• C. Chicken
• D. Tomatoes

Correct answer: B

Rationale: The correct answer is B: Watermelon. Watermelon is high in potassium, which is important to eat daily when taking furosemide to prevent hypokalemia. Furosemide is a diuretic that can lead to potassium loss, so consuming potassium-rich foods like watermelon helps maintain adequate potassium levels. Spaghetti, chicken, and tomatoes are not as high in potassium and therefore not as beneficial in preventing hypokalemia related to furosemide use.

4. At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

• A. Stay with the client and offer assistance with relaxation techniques
• B. Assess the client's pain level and administer pain medication if needed
• C. Bring the client a prescribed PRN sedative-hypnotic
• D. Encourage the client to engage in a quiet, non-stimulating activity until feeling sleepy

Correct answer: C

Rationale: At 0100 on the client's second postoperative night, the nurse should address the client's inability to sleep. Providing a prescribed PRN sedative-hypnotic is appropriate in this situation to help the client rest. Choice A is incorrect because leaving the room and closing the door does not directly address the client's sleep concern. Choice B is not the priority at this moment since the client's main issue is insomnia, not pain. Choice D, while encouraging a non-stimulating activity, does not provide immediate relief for the client's sleeplessness as a sedative-hypnotic would.

5. 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.

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