Nursing Elites

1. A healthcare professional reviewing the health care record of a client notes documentation of grade 4 muscle strength. The healthcare professional understands that this indicates:

• A. Full ROM with gravity
• B. Full ROM against gravity with full resistance
• C. Full ROM with gravity eliminated (passive motion)
• D. Full ROM against gravity with some resistance

Correct answer: D

Rationale: Muscle strength is graded on a scale of 0 to 5. A grade of 5 indicates normal strength and is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and full ROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity. Grade 2 indicates poor strength and full ROM with gravity eliminated (passive motion). Grade 1 indicates trace strength and slight contraction. Grade 0 indicates zero strength and no contraction. Therefore, the correct answer is 'Full ROM against gravity with some resistance.' Choices A, B, and C are incorrect as they do not match the description of muscle strength associated with a grade of 4.

2. When assessing a client with deep pitting edema, with the indentation remaining for a short time and visible leg swelling, how should a nurse document this finding?

• A. 1+ edema
• B. 2+ edema
• C. 3+ edema
• D. 4+ edema

Correct answer: C

Rationale: The correct answer is 3+ edema. When assessing for edema, the nurse presses thumbs against the ankle malleolus or the tibia. If the skin retains an indentation, it indicates pitting edema. The grading scale for pitting edema includes: 1+ for mild pitting with slight indentation and no perceptible leg swelling, 2+ for moderate pitting where the indentation subsides rapidly, 3+ for deep pitting with an indentation remaining briefly and visible leg swelling, and 4+ for very deep pitting with a long-lasting indentation and significant leg swelling. Choices A, B, and D do not accurately represent the severity of the edema described in the scenario.

3. A healthcare professional is reviewing the health care record of a client who has just undergone an examination of the internal genitalia. Which documented finding indicates an abnormality?

• A. The cervix is pink.
• B. The cervix is midline.
• C. The cervix is about 1 inch in diameter.
• D. Clear secretions with a foul odor are noted on the cervix.

Correct answer: D

Rationale: The correct answer is 'Clear secretions with a foul odor are noted on the cervix.' Normally, the cervix is pink, midline, and about 1 inch in diameter. Depending on the day of the menstrual cycle, secretions may vary. However, they should always be odorless and nonirritating. Secretions with a foul odor are indicative of an infection, making this finding abnormal. Choices A, B, and C describe normal cervix characteristics, so they do not indicate an abnormality in this scenario.

4. Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes serosanguinous drainage on the dressing. The most appropriate intervention is to:

• A. notify the physician of the drainage
• B. change the dressing
• C. reinforce the dressing
• D. apply an abdominal binder

Correct answer: C

Rationale: In the context of a classic cholecystectomy resection, serosanguinous drainage is an expected finding postoperatively due to the nature of the surgery. The appropriate intervention in this situation is to reinforce the dressing. Changing the dressing prematurely can increase the risk of introducing infection. Applying an abdominal binder is not recommended as it can obstruct the visualization of the dressing and the underlying wound, making it difficult to monitor for any complications or changes in drainage. Notifying the physician may be necessary if there are significant changes in the drainage characteristics or other concerning signs, but the immediate action should be to reinforce the dressing to maintain a clean and secure environment for wound healing.

5. The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?

• A. Health promotion
• B. Secondary prevention
• C. Tertiary prevention
• D. Primary prevention

Correct answer: B

Rationale: The nurse working with the client to explain what food and beverages might minimize aspiration is an example of secondary prevention. Secondary prevention involves early detection and intervention to prevent complications or worsening of a condition. In this case, the nurse is helping to prevent aspiration pneumonia by providing education and guidance on safe eating and drinking practices after the client has already experienced dysphagia due to a stroke. Choice A, health promotion, focuses on empowering individuals to adopt healthy behaviors to improve overall well-being and prevent illness. It is more about promoting general health rather than specific interventions related to a particular condition like dysphagia. Choice C, tertiary prevention, involves managing and rehabilitating a condition to prevent further complications or disabilities. In this scenario, the nurse is not yet addressing complications but rather actively preventing them. Choice D, primary prevention, aims to prevent the onset of a disease or condition before it occurs. The client in this case already has dysphagia, so the focus is on preventing further complications, making it a secondary prevention intervention.

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