Nursing Elites

1. A patient has been told to monitor her LH levels. Which of the following potential conditions might the patient be suffering from?

• A. Menorrhagia
• B. Grave's Disease
• C. Menopause
• D. Infertility

Correct answer: D

Rationale: Luteinizing hormone (LH) is released by the pituitary gland to stimulate ovulation. One of the common reasons for monitoring LH levels is infertility. In women with infertility, LH levels are monitored to time intercourse accurately to maximize the chances of conception. Menorrhagia (choice A) is characterized by heavy menstrual bleeding and is not directly related to LH levels. Grave's Disease (choice B) is an autoimmune disorder affecting the thyroid gland and is not typically monitored by LH levels. Menopause (choice C) is a natural process marking the end of a woman's reproductive years and is not a condition where LH monitoring for infertility is common.

2. When should you wear gloves?

• A. preparing infant formula for a newborn baby
• B. transferring breast milk into a baby bottle
• C. knocking on a patient's door
• D. opening a patient's door

Correct answer: B

Rationale: You must wear gloves when transferring breast milk into a baby bottle because breast milk is considered a bodily fluid. It is essential to avoid direct contact to prevent contamination. When preparing infant formula, gloves are not required as formula is not a bodily fluid. Knocking on or opening a patient's door does not involve direct contact with bodily fluids, so gloves are unnecessary in those situations.

3. Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?

• A. Vest restraints should be used because they are the least restrictive type.
• B. Restraints should be used for 48 hours in non-psychiatric patients.
• C. Restraints should be applied to prevent wandering behavior.
• D. Alternative measures must be attempted first.

Correct answer: D

Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.

4. The rehabilitation nurse wishes to make the following entry into a client's plan of care: 'Client will reestablish a pattern of daily bowel movements without straining within two months.' The nurse would write this statement under which section of the plan of care?

• A. Nursing diagnosis/problem list
• B. Nursing orders
• C. Short-term goals
• D. Long-term goals

Correct answer: D

Rationale: The correct answer is 'Long-term goals.' Long-term goals are designed to describe changes in client behavior expected over a time frame greater than one week. In this case, the goal of reestablishing a pattern of daily bowel movements without straining within two months falls under a long-term goal. Long-term goals are aimed at restoring normal functioning in a problem area and are beneficial for healthcare workers caring for the client across different settings. Choices A, B, and C are incorrect because nursing diagnosis/problem list, nursing orders, and short-term goals do not encompass the desired timeframe or level of expected change in this scenario.

5. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?

• A. No, this temperature is within normal limits.
• B. No, this temperature is normally hyperthermic.
• C. Yes, this temperature is highly hyperthermic.
• D. Yes, this temperature is highly hypothermic.

Correct answer: A

Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.

Similar Questions