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. A client has been coughing for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?

• A. Allergic reaction
• B. Ringworm
• C. Systemic lupus erythematosus
• D. Tuberculosis

Correct answer: D

Rationale: The correct answer is D: Tuberculosis. Coughing up blood (hemoptysis) is a key symptom of tuberculosis. Tuberculosis is a respiratory infection caused by the bacterium Mycobacterium tuberculosis. The other options are incorrect because an allergic reaction typically involves symptoms like itching, hives, or swelling, not coughing up blood. Ringworm is a fungal skin infection characterized by a red, circular rash, and systemic lupus erythematosus is an autoimmune disease that primarily affects joints and skin without causing hemoptysis.

3. A client who has a new prescription for warfarin (Coumadin) is receiving discharge teaching from a nurse. Which of the following statements indicates that the client understands the teaching?

• A. I will take my warfarin at the same time every day.
• B. I should use a soft-bristled toothbrush while taking this medication.
• C. I should take my warfarin at bedtime.
• D. I should avoid eating foods high in vitamin K while taking this medication.

Correct answer: A

Rationale: The correct answer is A. Taking warfarin at the same time every day is essential to maintain a consistent blood level of the medication. This statement indicates that the client understands the teaching about the importance of consistency in medication timing. Choice B, regarding using a soft-bristled toothbrush, is not directly related to warfarin therapy and does not assess the client's understanding of warfarin administration. Choice C suggesting taking warfarin at bedtime is incorrect; it is generally recommended to take warfarin at the same time each day to avoid variations in drug levels. Choice D about avoiding foods high in vitamin K is relevant as vitamin K can interfere with warfarin's anticoagulant effects. However, it is not the best indicator of understanding the teaching on medication timing, which is crucial for warfarin efficacy.

4. When caring for a patient diagnosed with diabetes mellitus and circulatory insufficiency, experiencing peripheral neuropathy and urinary incontinence, on which areas does the nurse focus care?

• A. Decreased pain sensation and increased risk of skin impairment
• B. Decreased caloric intake and accelerated wound healing
• C. High risk for skin infection and low saliva pH level
• D. High risk for impaired venous return and dementia

Correct answer: A

Rationale: The nurse should focus on decreased pain sensation and increased risk of skin impairment due to the patient's conditions. Peripheral neuropathy can lead to decreased pain sensation, making the patient more prone to injuries without realizing it. Additionally, the combination of circulatory insufficiency, peripheral neuropathy, and urinary incontinence can increase the risk of skin breakdown and impaired healing. Choices B, C, and D are incorrect because they do not address the specific issues related to the patient's diagnoses and symptoms.

5. 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 and the client did this. 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: The appropriate comment by the nurse is to affirm the correct technique while offering support and checking for any issues during the insertion.

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