Nursing Elites

1. The nurse is observing the way a patient walks. What aspect is the nurse assessing?

• A. Body alignment
• B. Gait
• C. Activity tolerance
• D. Range of motion

Correct answer: B

Rationale: The correct answer is B: Gait. Gait refers to the manner in which a person walks, including aspects such as stride length, step width, and walking speed. When a nurse observes a patient's gait, they are assessing their mobility and looking for any abnormalities or issues in their walking pattern. Choice A, body alignment, focuses more on the posture and position of the body rather than the actual walking pattern. Choice C, activity tolerance, relates to the ability to withstand physical activity without experiencing excessive fatigue. Choice D, range of motion, pertains to the extent of movement at a joint and is not directly related to observing the way a patient walks.

2. Which action should the nurse take to minimize the risk of medication errors?

• A. Prepare medications ahead of time to ensure they are ready.
• B. Ensure two nurses double-check medications before administration.
• C. Administer medications at the same time each day.
• D. Rely on memory to administer the correct medications.

Correct answer: B

Rationale: The correct answer is B because ensuring two nurses double-check medications before administration is a crucial step in minimizing the risk of medication errors. This practice helps in verifying the accuracy of medication orders and reducing the chances of mistakes. Choice A may not necessarily prevent errors as preparing medications ahead of time does not guarantee accuracy. Choice C, administering medications at the same time each day, is important for consistency but does not directly address the risk of errors. Choice D, relying on memory, is highly discouraged as it increases the likelihood of errors due to human forgetfulness.

3. What are the clinical manifestations of hypovolemic shock, and how should a nurse respond?

• A. Hypertension, bradycardia, and oliguria
• B. Bradycardia, hypertension, and peripheral edema
• C. Tachypnea, cool skin, and confusion
• D. Tachycardia, hypotension, and decreased urine output

Correct answer: D

Rationale: The correct answer is D: Tachycardia, hypotension, and decreased urine output are classic clinical manifestations of hypovolemic shock. In hypovolemic shock, the body tries to compensate for low blood volume by increasing the heart rate (tachycardia) to maintain cardiac output, leading to hypotension and decreased urine output. Prompt fluid replacement is necessary to restore intravascular volume. Choices A, B, and C are incorrect because they do not represent the typical manifestations of hypovolemic shock.

4. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

• A. Giving a glycerin suppository to a client for constipation
• B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache
• C. Discussing dietary changes with a client who has a prescription for a gluten-free diet
• D. Measuring hourly urinary output for a client who is postoperative

Correct answer: D

Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.

5. A nurse is providing discharge teaching to a client following a myocardial infarction (MI). Which of the following activities should the client avoid?

• A. Swimming in a pool
• B. Driving a car
• C. Light housework
• D. Walking on flat ground

Correct answer: B

Rationale: The correct answer is B: Driving a car. Driving a car can be physically and emotionally taxing, increasing the risk of complications soon after a myocardial infarction. It requires quick reflexes and decision-making abilities, which may be impaired during the recovery period. Swimming in a pool, light housework, and walking on flat ground are generally safe and beneficial activities for clients following a myocardial infarction as they promote circulation, muscle strength, and overall well-being.

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