Nursing Elites

1. A client is receiving teaching from a healthcare provider about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will perform ankle and knee exercises every hour - Range of motion (ROM) is needed to prevent contractures.
• B. I will hold my breath when rising from a sitting position.
• C. I will remove my antiembolic stockings while I am in bed.
• D. I will have my partner help me change positions every 4 hours.

Correct answer: A

Rationale: Choice A is correct because performing ankle and knee exercises every hour helps prevent contractures and other adverse effects of immobility. Contractures are a common complication of immobility, and range of motion (ROM) exercises can help maintain joint flexibility and prevent contractures. This statement indicates an understanding of the teaching provided by the healthcare provider. Choices B, C, and D are incorrect. Holding the breath when rising from a sitting position can increase the risk of orthostatic hypotension, not reduce adverse effects of immobility. Removing antiembolic stockings while in bed can compromise their effectiveness in preventing deep vein thrombosis (DVT), which is not a measure to reduce immobility-related complications. Having a partner help change positions every 4 hours may not be frequent enough to prevent immobility-related complications effectively; changing positions more frequently is usually recommended to prevent issues like pressure ulcers and muscle stiffness.

2. A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?

• A. Empty the drainage bag at least every 8 hours
• B. Keep the drainage bag below the level of the bladder
• C. Use sterile technique to collect a specimen from the drainage system
• D. Secure the catheter to the lower abdomen with a securement device

Correct answer: B

Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).

3. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?

• A. Administer oxygen via a nasal cannula.
• B. Measure the client's vital signs.
• C. Obtain a 12-lead ECG.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: A

Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.

4. A mother tells the nurse that her 2-year-old toddler has temper tantrums and says 'no' every time the mother tries to help them get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development?

• A. Trying to increase independence.
• B. Developing a sense of trust.
• C. Establishing a new identity.
• D. Attempting to master a skill.

Correct answer: A

Rationale: The correct answer is A: Trying to increase independence. Toddlers around the age of 2 often exhibit behaviors like temper tantrums and saying 'no' as they are asserting their independence and autonomy. This behavior is a normal part of their developmental stage where they are starting to explore and assert their own preferences and desires. Choice B, developing a sense of trust, is more relevant to infants during the trust vs. mistrust stage. Choice C, establishing a new identity, is typically associated with adolescence and identity formation. Choice D, attempting to master a skill, is more indicative of a child trying to learn and develop new abilities rather than the behavior described in the scenario.

5. A healthcare professional is assessing a client’s extraocular eye movements. Which of the following should the professional do?

• A. Instruct the client to follow a finger through the six cardinal positions of gaze.
• B. Hold a finger 46 cm (18 in) away from the client’s eyes.
• C. Ask the client to cover their right eye during assessment of the left eye.
• D. Position the client 6.1 m (20 feet) away from the Snellen chart.

Correct answer: A

Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action when assessing extraocular eye movements. This technique assesses the movement of the eyes in all directions and helps to test cranial nerves 3, 4, and 6, which control eye movements. Choice B is incorrect as the distance mentioned is not relevant for assessing extraocular eye movements. Choice C is incorrect as both eyes need to be assessed independently. Choice D is incorrect as positioning the client 6.1 m (20 feet) away from the Snellen chart is related to visual acuity testing, not extraocular eye movements.

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