Nursing Elites

1. What is the primary purpose of performing range-of-motion (ROM) exercises?

• A. To improve cardiovascular fitness
• B. To prevent muscle atrophy and joint contractures
• C. To increase respiratory function
• D. To enhance cognitive function

Correct answer: B

Rationale: The primary purpose of performing range-of-motion (ROM) exercises is to prevent muscle atrophy and joint contractures. These exercises are crucial in maintaining joint mobility and muscle flexibility, especially in patients who are immobilized or have limited mobility. Improving cardiovascular fitness (Choice A) involves different types of exercises that target the heart and blood vessels, not specifically ROM exercises. Increasing respiratory function (Choice C) is typically achieved through breathing exercises and activities that enhance lung capacity. Enhancing cognitive function (Choice D) is usually addressed through cognitive exercises and activities that stimulate brain function.

2. Based on the principle of asepsis, which situation should the nurse consider to be sterile?

• A. A one-inch border around the edges of a sterile field set up in the operating room
• B. A sterile glove that the nurse thinks might have touched her hair
• C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp tabletop
• D. An open sterile Foley catheter kit set up on a table at the nurse's waist level

Correct answer: D

Rationale: The correct answer is D because an open sterile Foley catheter kit set up at waist level is considered sterile if it has not been contaminated. Choice A is incorrect because the one-inch border around a sterile field is considered non-sterile. Choice B is incorrect because a sterile glove that might have touched the nurse's hair is likely contaminated. Choice C is incorrect because a wrapped, unopened sterile gauze pad placed on a damp tabletop may have become contaminated.

3. When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma?

• A. Antiseptic cream
• B. Petroleum jelly
• C. Cornstarch
• D. Stomadhesive

Correct answer: D

Rationale: The correct answer is 'Stomadhesive.' Stomadhesive is a protective barrier used around the stoma to prevent skin irritation and to secure the colostomy bag. This preparation helps to maintain skin integrity and prevent complications such as skin breakdown. Antiseptic cream (Choice A) is not typically used around the stoma as it can irritate the skin. Petroleum jelly (Choice B) is also not recommended as it can interfere with the adhesive properties of the colostomy appliance. Cornstarch (Choice C) is not suitable for application around the stoma as it can promote moisture and lead to skin irritation.

4. The PN determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the PN take?

• A. Protect the client's feet from injury
• B. Apply a heating pad to the affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is the most appropriate action for a client with cirrhosis experiencing peripheral neuropathy. Peripheral neuropathy can lead to a loss of sensation, making the client prone to unnoticed injuries. Applying a heating pad (Choice B) is contraindicated as it may cause burns or further damage to the affected area. Keeping the client's feet elevated (Choice C) is not directly related to managing peripheral neuropathy and may not provide significant benefit. Assessing the feet and legs for jaundice (Choice D) is important for monitoring liver function in clients with cirrhosis, but in this case, the priority is to prevent injury to the feet due to decreased sensation.

5. While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the nurse implement first?

• A. Administer sublingual nitroglycerin
• B. Assist the client back to the room
• C. Have the client sit down in the hall
• D. Obtain a 12-lead electrocardiogram

Correct answer: C

Rationale: Having the client sit down in the hallway is the first action the nurse should implement. This is crucial to prevent further strain on the heart and to provide a safer environment for assessment and potential emergency intervention. Administering sublingual nitroglycerin (Choice A) may be appropriate later but should not precede ensuring the client's immediate safety. Assisting the client back to the room (Choice B) may not be advisable if the client is experiencing chest tightness and shortness of breath. Obtaining a 12-lead electrocardiogram (Choice D) is important but would not be the initial action to address the client's immediate symptoms.

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