Nursing Elites

1. The nurse is caring for a patient who has experienced a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive range of motion (ROM) will be initiated. When should the nurse begin this therapy?

• A. After the acute phase of the disease has passed.
• B. As soon as the ability to move is lost.
• C. Once the patient enters the rehab unit.
• D. When the patient requests it.

Correct answer: B

Rationale: Passive ROM exercises should begin as soon as the patient loses the ability to move the extremity or joint. Initiating passive ROM early helps prevent contractures and maintain joint function. Choice A is incorrect because delaying passive ROM until after the acute phase may lead to irreversible contractures. Choice C is not the best option as waiting until the patient enters the rehab unit delays crucial preventive measures. Choice D is incorrect as passive ROM should not be based on patient requests but on clinical indications and best practices.

2. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take?

• A. Alert the American Nurses Association.
• B. Fill out an incident report.
• C. Report the observations to the nurse manager on the unit.
• D. Leave the nurse alone to sleep.

Correct answer: C

Rationale: Reporting the observations to the nurse manager is the appropriate action to ensure the safety of the clients and address potential impairment. The nurse manager can take necessary steps to assess the situation and intervene if needed. Alerting the American Nurses Association (Choice A) is not necessary at this stage as the immediate concern is the safety of clients in the unit. Filling out an incident report (Choice B) may be required later, but the priority is to address the issue promptly by involving the immediate supervisor. Leaving the nurse alone to sleep (Choice D) is not a safe option as it does not address the underlying problem of potential impairment and safety concerns; it is essential to address the issue promptly to ensure patient safety.

3. What are the correct steps used for abdominal assessment?

• A. Inspection, auscultation, percussion, palpation
• B. Palpation, inspection, auscultation, percussion
• C. Percussion, palpation, inspection, auscultation
• D. Auscultation, palpation, percussion, inspection

Correct answer: A

Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation follows to listen for bowel sounds and vascular sounds. Percussion helps to assess the density of underlying structures and detect any abnormal masses. Palpation is performed last to assess tenderness, organ size, and detect any masses. Choices B, C, and D have the steps in the incorrect order, making them the wrong choices.

4. The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?

• A. Observe the appearance of the skin under the ice pack.
• B. Instruct the client regarding the importance of the covering.
• C. Reapply the covering after filling it with fresh ice.
• D. Ask the client how long the ice pack was applied to the skin.

Correct answer: A

Rationale: The correct first action for the nurse to take when a client removes the covering from an ice pack is to observe the appearance of the skin under the ice pack. This assessment is crucial to check for any skin damage or adverse reactions resulting from direct contact with the ice pack. Instructing the client about the importance of the covering (Choice B) can follow the skin assessment. Reapplying the covering (Choice C) before skin assessment may potentially cause harm. Asking the client about the duration of ice application (Choice D) is not the immediate priority; ensuring skin integrity is the primary concern.

5. A client who has had an allogeneic stem cell transplant needs protective measures. What precaution should the nurse plan for this client?

• A. Ensure the client wears a mask when outside the room if there is construction nearby.
• B. Place the client in a private room with positive pressure airflow.
• C. Restrict all visitors from seeing the client.
• D. Provide a HEPA filter in the client's room.

Correct answer: A

Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to minimize exposure to potential sources of infection. Wearing a mask when outside the room, especially in areas with construction or other potential risks, helps protect the client's compromised immune system. Positive pressure airflow rooms are typically used for clients with airborne infections, not for those post-stem cell transplant. Restricting all visitors may contribute to the client's well-being, but it is not a direct protective measure against infection. While HEPA filters can be beneficial in maintaining air quality, wearing a mask when exposed to external risks is a more targeted and immediate protective measure in this scenario.

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