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 16-year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?

• A. Ask the teenager to wait until a parent or legal guardian can be contacted
• B. Withhold treatment until telephone consent can be obtained from the partner
• C. Refer the teenager to a community pediatric hospital emergency department
• D. Proceed with the triage process in the same manner as any adult client

Correct answer: D

Rationale: The correct answer is to proceed with the triage process in the same manner as any adult client. In this scenario, since the teenager is legally married, they have the legal authority to consent to their own treatment. Choice A is incorrect because the teenager, being legally married, can provide their own consent. Choice B is incorrect as it unnecessarily delays treatment by waiting for telephone consent from the partner, which is not required in this case. Choice C is incorrect as the teenager can receive appropriate care in the current emergency department setting without the need for referral.

3. Which task can the RN delegate to an unlicensed assistive personnel (UAP)?

• A. Take a history on a newly admitted client
• B. Adjust the rate of a gastric tube feeding
• C. Check the blood pressure of a 2-hour postoperative client
• D. Check on a client receiving chemotherapy

Correct answer: C

Rationale: The correct answer is C. Checking the blood pressure of a 2-hour postoperative client is a task that can be safely delegated to an unlicensed assistive personnel (UAP) as it falls within their scope of practice. This task is routine and does not require specialized nursing knowledge or critical decision-making. Options A, B, and D involve tasks that require a higher level of training and critical thinking beyond the scope of a UAP. Taking a history, adjusting tube feeding rates, and monitoring a client receiving chemotherapy are responsibilities that should be performed by licensed healthcare providers who have the necessary skills and training.

4. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include?

• A. Writing a prescription for morphine sulfate as needed for pain
• B. Inserting a nasogastric (NG) tube to relieve gastric distention
• C. Showing a client how to use progressive muscle relaxation
• D. Performing a daily bath after the evening meal

Correct answer: C

Rationale: The correct answer is C. Showing a client how to use progressive muscle relaxation is an intervention that does not require a provider's prescription. This falls within the nurse's scope of practice and can be implemented to promote relaxation and reduce stress for the client. Choices A and B involve tasks that require a provider's prescription and specialized training. Writing a prescription for morphine sulfate and inserting an NG tube should only be done by authorized healthcare providers. Choice D, performing a daily bath, while within the nurse's scope, does not specifically address interventions that do not require a provider's prescription.

5. The healthcare provider is assessing a client with acute pancreatitis. Which finding is most concerning?

• A. Pain radiating to the back
• B. Blood pressure of 95/60 mmHg
• C. Elevated serum amylase
• D. Absent bowel sounds

Correct answer: B

Rationale: In acute pancreatitis, a low blood pressure of 95/60 mmHg is the most concerning finding as it may indicate hypovolemia or shock, which are critical conditions requiring immediate intervention. Pain radiating to the back is a common symptom of pancreatitis but is not as immediately life-threatening as hypotension. Elevated serum amylase levels and absent bowel sounds are typical findings in acute pancreatitis and may indicate pancreatic inflammation and gastrointestinal motility issues, respectively, but they are not as acutely concerning as hypotension.

Similar Questions