Nursing Elites

1. Which client assessment falls within the scope of practice for the practical nurse?

• A. An agitated client with bilateral wrist restraints
• B. New admission of a client with deep vein thrombosis
• C. Return of a post-anesthesia client following a colon resection
• D. Transfer of a client with sepsis from a long-term care facility

Correct answer: B

Rationale: The correct answer is B because assessing a new deep vein thrombosis (DVT) patient is within the scope of practical nursing. It involves monitoring and supporting the circulatory system health, which is a common responsibility for practical nurses. Choices A, C, and D involve scenarios that are typically beyond the initial assessment and care provided by practical nurses. An agitated client with bilateral wrist restraints may require immediate intervention by higher-level healthcare providers due to safety concerns and potential underlying issues. The return of a post-anesthesia client following a colon resection and the transfer of a client with sepsis involve more specialized care that goes beyond the typical responsibilities of a practical nurse, often requiring interventions from registered nurses or physicians.

2. Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?

• A. Assess the client's hemoglobin levels to determine if the client is in shock
• B. Call the surgeon and prepare to take the client back to the operating room
• C. Outline the area with ink and check it every 15 minutes to monitor for changes in bleeding
• D. No action is required as postoperative bleeding can be expected

Correct answer: C

Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.

3. A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?

• A. Administer insulin as prescribed
• B. Provide a carbohydrate-controlled snack
• C. Encourage physical activity
• D. Recheck the blood sugar

Correct answer: A

Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.

4. A new mother is at the clinic with her 4-week-old for a well-baby check-up. The nurse should tell the mother to anticipate that the infant will demonstrate which milestone by 2 months of age?

• A. Turns from side to back and returns
• B. Consistently returns smiles to mother
• C. Finds hands and plays with fingers
• D. Holds head up and supports weight with arms

Correct answer: B

Rationale: The correct answer is B because social smiling is a developmental milestone typically expected around 2 months of age. At this stage, infants start to engage more with their caregivers and show positive emotional responses. The other choices are incorrect. Choice A describes a motor skill that usually emerges later. Choice C involves more coordination and exploration, which is not typically seen by 2 months. Choice D relates to head control and arm strength, which also develop progressively but may not be fully achieved by 2 months.

5. What are the final factors that contribute to blood pressure? (Select all that apply)

• A. Heart rate
• B. Stroke volume
• C. Peripheral resistance
• D. Neuroendocrine hormones

Correct answer: D

Rationale: Neuroendocrine hormones play a crucial role in regulating blood pressure by influencing factors like fluid balance, blood volume, and vessel constriction. While heart rate, stroke volume, and peripheral resistance are important factors affecting blood pressure, the final parameters that directly produce blood pressure are influenced by neuroendocrine hormones. Therefore, choice D is the correct answer. Choices A, B, and C are involved in the regulation of blood pressure but are not the final parameters that directly produce it.

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