Nursing Elites

1. The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following? (Select all that apply)

• A. Obtain the pulses in all four extremities
• B. Ask the client to grasp and squeeze two fingers on each of the nurse’s hands
• C. Determine the client’s orientation to person, place, and time
• D. B, C

Correct answer: D

Rationale: The correct answer is 'D' because assessing grasp strength (choice B) and orientation to person, place, and time (choice C) are crucial components of a neurological assessment following a cerebrovascular accident (CVA). Pulse assessment in all four extremities (choice A) is not directly related to a neurological assessment and is more pertinent to vascular status. Therefore, choices A and D are incorrect in this context.

2. Participating in the development of long-term and preventive health goals with the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: B

Rationale: The correct answer is B: Planning. Planning in nursing care involves setting long-term and preventive goals for the patient in collaboration with the patient and their family. This step ensures that a comprehensive and individualized care plan is developed. Choice A, Evaluation, comes after the interventions have been implemented to assess their effectiveness. Choice C, Implementation, is the step where the care plan is put into action. Choice D, Assessment, is the initial step that involves collecting data to identify the patient's needs, which is done before planning the care.

3. During synchronized cardioversion on a client in atrial fibrillation, when the machine is activated, and there is a pause, what action should the nurse take?

• A. Wait until the machine discharges
• B. Shout “all clear” and don’t touch the bed
• C. Make sure the client is all right
• D. Increase the joules and re-discharge

Correct answer: B

Rationale: The correct action for the nurse to take when there is a pause after the machine is activated during synchronized cardioversion is to shout “all clear” and ensure that no one is touching the client or the bed to prevent them from being shocked. This step is crucial for the safety of everyone present during the procedure. Choices A, C, and D are incorrect because waiting without confirming safety, focusing on the client's condition only, or increasing joules without safety precautions can lead to potential harm or injury.

4. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

• A. The assistant is putting the stockings on while the client is in the chair
• B. The assistant inserted two (2) fingers under the proximal end of the stocking
• C. The assistant elevated the feet while lying down to put on the stockings
• D. The assistant made sure the toes were warm after putting the stockings on

Correct answer: A

Rationale: The correct answer is A. Compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is incorrect as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C is incorrect as elevating the feet while lying down is a correct technique for applying compression stockings. Choice D is incorrect as ensuring the toes are warm after putting the stockings on is a good practice for client comfort.

5. During a synchronized cardioversion on a client in atrial fibrillation, when the machine is activated and there is a pause, what action should the nurse take?

• A. Wait until the machine discharges
• B. Shout “all clear” and don’t touch the bed
• C. Make sure the client is all right
• D. Increase the joules and re-discharge

Correct answer: B

Rationale: The correct action for the nurse to take when there is a pause after activating the machine for synchronized cardioversion on a client in atrial fibrillation is to shout “all clear” and not touch the bed. This step is crucial to ensure the safety of everyone present by warning them that the machine will discharge, preventing anyone from being inadvertently shocked. Waiting for the machine to discharge (choice A) is not recommended as it can lead to accidental injury. While ensuring the client is all right (choice C) is important, the immediate focus should be on safety during the procedure. Increasing the joules and re-discharging (choice D) without assessing the situation can pose risks to the client and the healthcare team.

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