Nursing Elites

1. The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use?

• A. Supine position
• B. Lateral position
• C. Lateral position with positioning supports
• D. Supine position with no pillow under the patient's head

Correct answer: B

Rationale: When assessing body alignment for an immobilized patient, the nurse should use the lateral position. This position helps in assessing alignment and preventing complications such as pressure ulcers. The supine position (Choice A) may not provide an accurate assessment of body alignment in an immobilized patient. While a lateral position with positioning supports (Choice C) may be used for comfort, it is not specifically for assessing body alignment. Using the supine position without a pillow under the patient's head (Choice D) is not ideal for assessing body alignment in an immobilized patient as it may not accurately reflect the patient's overall alignment.

2. The nurse is caring for a client with hyperthyroidism. Which finding should the nurse expect to observe in this client?

• A. Weight loss
• B. Cold intolerance
• C. Bradycardia
• D. Dry skin

Correct answer: A

Rationale: Weight loss is a common finding in clients with hyperthyroidism due to increased metabolic activity. Hyperthyroidism leads to an overactive thyroid gland, which results in an increased metabolic rate and often leads to weight loss despite a normal or increased appetite. Cold intolerance (Choice B) is more commonly associated with hypothyroidism, where the body's processes slow down. Bradycardia (Choice C) is a slow heart rate, which is not typically seen in hyperthyroidism; rather, tachycardia or an increased heart rate is more common. Dry skin (Choice D) is also not a typical finding in hyperthyroidism, as the skin is more likely to be warm and moist due to increased metabolic activity.

3. During a physical assessment, a nurse is assessing 4 adult clients. Which of the following physical assessment techniques should the nurse use?

• A. Ensure the bladder of the BP cuff surrounds 80% of their arm.
• B. Use the BP cuff on the forearm if the upper arm is not accessible.
• C. Apply the BP cuff loosely around the arm.
• D. Use a pediatric cuff for adults with small arms.

Correct answer: A

Rationale: The correct answer is to ensure the bladder of the BP cuff surrounds 80% of the arm. This technique is crucial for obtaining accurate blood pressure readings. Choice B is incorrect because using the BP cuff on the forearm may lead to inaccurate readings. Choice C is incorrect as applying the BP cuff loosely can also result in inaccurate measurements. Choice D is incorrect because using a pediatric cuff for adults with small arms would not provide accurate blood pressure readings.

4. When orienting a newly licensed nurse on taking a telephone prescription, which statement indicates understanding of the process?

• A. A second nurse enters the prescription into the client’s medical record.
• B. Another nurse should listen to the phone call.
• C. The provider can clarify the prescription when they sign the health record.
• D. I should omit the 'read back' if this is a one-time prescription.

Correct answer: A

Rationale: The correct answer is A because a second nurse should verify and enter the prescription into the client’s medical record to ensure accuracy. This step is crucial to prevent errors in transcription and administration. Choice B is incorrect as having another nurse listen to the phone call does not ensure accurate transcription. Choice C is incorrect because the provider clarifying the prescription upon signing the health record does not replace the need for proper documentation. Choice D is incorrect because the 'read back' process is essential for all telephone prescriptions to confirm accuracy and prevent errors in transcription or administration.

5. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

• A. Obtain client information
• B. Develop a plan of care
• C. Implement nursing interventions
• D. Evaluate the client's response to treatment

Correct answer: A

Rationale: The correct answer is A: Obtain client information. The first step in the nursing process is assessment, which involves gathering data about the client's condition, needs, and preferences. This information forms the foundation for developing a comprehensive plan of care. Developing a plan of care (Choice B) comes after assessment to address the identified needs. Implementing nursing interventions (Choice C) follows the development of the plan of care. Evaluating the client's response to treatment (Choice D) occurs after implementing the interventions to determine the effectiveness of the care provided. Therefore, the initial and priority step is to obtain client information through assessment.

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