Nursing Elites

1. How can the nurse promote relief of muscle pain, spasms, and tension?

• A. Encouraging the client to continue their activities as usual.
• B. Immobilizing the client.
• C. Applying heat, cold, pressure, or vibration to the painful area.
• D. Administering pain medication as needed to ease the muscle.

Correct answer: C

Rationale: To promote relief of muscle pain, spasms, and tension, the nurse should consider applying heat, cold, pressure, or vibration to the painful area. These interventions can help alleviate pain associated with muscle tension, pain, or spasms. Choice A is incorrect because encouraging the client to continue their activities as usual may exacerbate the pain. Choice B is incorrect as immobilizing the client may not address the underlying issue and could potentially lead to further complications. Choice D is also incorrect because while pain medication can be used, it is not the first-line treatment for muscle pain, spasms, and tension.

2. To determine the standards of care for the institution, the nurse should consult?

• A. Organizational Chart
• B. Personnel policies
• C. Policies and procedure manual
• D. Job descriptions

Correct answer: C

Rationale: The correct answer is the 'Policies and procedure manual.' This manual outlines the policies and procedures that govern patient care within the institution, including the standards of care that healthcare providers are expected to follow. Consulting the policies and procedure manual ensures that the nurse is adhering to the established guidelines and protocols. Choices A, B, and D are incorrect because although they are important documents within an institution, they do not specifically define the standards of care for patient management. The organizational chart illustrates the hierarchy of the institution, personnel policies outline rules related to employees, and job descriptions detail specific roles and responsibilities, none of which directly define patient care standards.

3. Elderly persons with pernicious anemia should be instructed:

• A. to increase their dietary intake of foods high in B12.
• B. that they do not need to return for follow-up for at least a month after initiation of treatment.
• C. that oral B12 is safer and less expensive than parenteral replacement.
• D. that diarrhea can be a transient side effect of B12 injections.

Correct answer: D

Rationale: Elderly persons with pernicious anemia, a condition characterized by vitamin B12 deficiency due to lack of intrinsic factor, should be informed about the potential side effects of B12 injections. Diarrhea is a known transient side effect of B12 injections, along with pain and burning at the injection site, and peripheral vascular thrombosis. Increasing dietary intake of B12-rich foods would not be sufficient due to the malabsorption issue in pernicious anemia. Follow-up is essential in managing pernicious anemia, so instructing patients they do not need to return for follow-up is incorrect. While oral B12 may be a suitable option for some cases, it is not the preferred choice for pernicious anemia where malabsorption is the primary issue.

4. Which action by a graduate nurse would require the charge nurse to intervene?

• A. Walking in the hallway outside the operating room without a hair covering
• B. Putting on a surgical mask, gown, and cap before entering the operating room
• C. Wearing a surgical mask into the holding area
• D. Wearing scrubs from home into the nursing station

Correct answer: A

Rationale: The correct answer is walking in the hallway outside the operating room without a hair covering. In healthcare settings, it is crucial to adhere to infection control measures, which include wearing appropriate attire to prevent the spread of pathogens. Walking in the hallway outside the operating room without a hair covering violates these infection control protocols, necessitating immediate intervention by the charge nurse. Choices B and C are incorrect because putting on surgical attire before entering the operating room and wearing a surgical mask into the holding area are both standard practices that promote patient safety and infection control. Choice D is also incorrect as wearing scrubs from home into the nursing station, while not ideal, is not a violation that warrants immediate intervention compared to breaching infection control protocols near sensitive areas like the operating room.

5. Signs of impaired breathing in infants and children include all of the following except:

• A. nasal flaring
• B. grunting
• C. seesaw breathing
• D. quivering lips

Correct answer: D

Rationale: Signs of impaired breathing in infants and children typically include nasal flaring, grunting, and seesaw breathing. Nasal flaring is the widening of the nostrils during breathing to help with air intake, grunting is a sound made during expiration to keep the airway open, and seesaw breathing is an abnormal pattern where the chest moves in while the abdomen moves out. Quivering lips are not a typical sign of impaired breathing in infants and children, making it the correct answer. Nasal flaring, grunting, and seesaw breathing are all signs indicating the need for immediate medical attention due to potential respiratory distress.

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