Nursing Elites

1. The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?

• A. Raise the bed to a comfortable working level.
• B. Bend the client's knee.
• C. Move the knee toward the chest as far as it will go.
• D. Cradle the client's heel.

Correct answer: D

Rationale: When providing passive ROM exercises to the hip and knee for an unconscious client, it is essential to support the joints of the knee and ankle. The next action should be to cradle the client's heel and gently move the limb in a slow, smooth, firm, but gentle manner. This helps maintain joint mobility and prevent contractures.

2. After surgery, a patient has decreased cardiac output. What is a likely observation by the nurse?

• A. Decreased urine output
• B. Increased urine output
• C. Flushing of the skin
• D. Hyperventilation

Correct answer: A

Rationale: A decrease in cardiac output can lead to decreased blood flow to the kidneys, resulting in decreased urine output. The kidneys rely on adequate blood supply to filter waste and produce urine. Therefore, a decreased urine output is a common observation when cardiac output is reduced. Choices B, C, and D are incorrect. Increased urine output is not typically associated with decreased cardiac output; flushing of the skin is more related to vasodilation, and hyperventilation is not directly linked to decreased cardiac output.

3. The client was placed in restraints due to confusion while hospitalized. The family removes the restraints in the client's presence. After the family leaves, what should the nurse do first?

• A. Apply the restraints to ensure the client's safety.
• B. Reassess the client to determine if restraints are still necessary.
• C. Document the time the family departed and continue monitoring the client.
• D. Contact the healthcare provider for a new order.

Correct answer: B

Rationale: In this scenario, the nurse's initial action should be to reassess the client to determine if restraints are still necessary following their removal by the family. This reassessment is crucial to evaluate the client's current condition and the need for restraints before considering reapplication. By reassessing first, the nurse ensures that the client's safety is maintained while respecting their autonomy. While documentation and monitoring are important, reassessment takes priority to provide individualized and appropriate care to the client. Contacting the healthcare provider for a new order should occur after reassessment if restraints are deemed necessary.

4. The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?

• A. Provide an interpreter to convey the meaning of words and messages in translation
• B. Commend the client for her patience during a long wait in the admission process
• C. Arrange for the hospital chaplain to visit the client during her hospital stay
• D. Rely on cultural norms as the basis for providing healthcare for this client

Correct answer: D

Rationale: When caring for patients from diverse cultural backgrounds, it is essential to respect and consider their cultural norms and practices while providing healthcare. Understanding and incorporating cultural beliefs and values can enhance the quality of care and improve patient outcomes.

5. In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?

• A. Daily black, sticky stool
• B. Daily dark brown stool
• C. Firm brown stool every other day
• D. Soft light brown stool twice a day

Correct answer: A

Rationale: The correct answer is A: Daily black, sticky stool. Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. This finding indicates the presence of digested blood in the stool. Choices B, C, and D describe variations of normal stool color and consistency, which do not raise immediate concerns related to gastrointestinal bleeding.

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