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. The nurse is caring for a client diagnosed with hypothyroidism. Which finding should the nurse expect to observe?

• A. Weight gain
• B. Heat intolerance
• C. Increased appetite
• D. Frequent diarrhea

Correct answer: A

Rationale: The correct answer is weight gain. In hypothyroidism, there is a decrease in metabolic rate, which can lead to weight gain. Heat intolerance (choice B) is more commonly associated with hyperthyroidism. Increased appetite (choice C) and frequent diarrhea (choice D) are not typical findings in hypothyroidism. Therefore, choices B, C, and D are incorrect.

3. A healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?

• A. Constant bubbling in the suction control chamber
• B. Intermittent bubbling in the water seal chamber
• C. Drainage of 50 ml per hour
• D. Crepitus around the insertion site

Correct answer: D

Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, a serious condition that requires immediate attention. It can be a sign of an air leak in the lung or surrounding tissues. Constant bubbling in the suction control chamber is expected in a functioning chest tube system as it indicates proper suction. Intermittent bubbling in the water seal chamber is also normal, showing that the system is functioning correctly, allowing air to escape but not re-enter. Drainage of 50 ml per hour is within the expected range for chest tube output and does not require immediate intervention unless there are other concerning signs such as rapid increase or a sudden change in color or consistency.

4. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

• A. Protective environment
• B. Airborne precautions
• C. Droplet precautions
• D. Contact precautions

Correct answer: D

Rationale: The correct answer is D: Contact precautions. When a client has an abdominal wound with purulent drainage, contact precautions are necessary to prevent the spread of infection through direct contact. Protective environment precautions are used for immunocompromised clients, airborne precautions are for diseases transmitted by airborne particles, and droplet precautions are for diseases transmitted by respiratory droplets. In this case, the focus is on preventing direct contact transmission, making contact precautions the most appropriate choice. Protective environment, airborne, and droplet precautions are not indicated in this scenario because the primary concern is the direct contact transmission of pathogens through the wound drainage.

5. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

• A. Use the complete name of the medication magnesium sulfate.
• B. Delete the space between the numerical dose and the unit of measure.
• C. Write the letter U when noting the dosage of insulin.
• D. Use the abbreviation SC when indicating an injection.

Correct answer: A

Rationale: The correct answer is to use the complete name of the medication magnesium sulfate. This is important to prevent confusion with morphine sulfate, which is abbreviated as MSO4. Choice B is incorrect as it is essential to maintain a space between the numerical dose and the unit of measure for clarity in medication documentation. Choice C is incorrect as the standard abbreviation for units is 'U' for international units, not for the dosage of insulin. Choice D is incorrect as the appropriate abbreviation for subcutaneous injection is 'SC,' not just 'SC.' Therefore, the nurse manager should emphasize using the full name of medications to avoid errors and ensure patient safety.

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