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. All of the following are posture and body alignment problems EXCEPT:

• A. Kyphosis
• B. Scoliosis
• C. Thrombosis
• D. Lumbar lordosis

Correct answer: C

Rationale: Thrombosis is a condition involving blood clots and is not related to posture or body alignment, unlike kyphosis, scoliosis, and lumbar lordosis, which are spinal alignment issues. Kyphosis refers to excessive outward curvature of the spine, scoliosis is characterized by a sideways curvature of the spine, and lumbar lordosis involves an exaggerated inward curve in the lower back. Thrombosis, on the other hand, is a condition where blood clots form in the blood vessels, not a posture or body alignment problem.

3. When caring for a patient with a fresh tracheostomy, what is the nurse’s first priority?

• A. Providing humidified oxygen
• B. Ensuring the tracheostomy ties are secure
• C. Suctioning the tracheostomy tube as needed
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The correct answer is B: Ensuring the tracheostomy ties are secure. This is the nurse's first priority because it is critical to prevent accidental decannulation, which could compromise the patient’s airway. Providing humidified oxygen, suctioning the tracheostomy tube, and monitoring for signs of infection are important aspects of care but ensuring the tracheostomy ties' security takes precedence to maintain the patient's airway.

4. A client with peripheral neuropathy due to cirrhosis is at risk for injury. What should the nurse do?

• 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 critical as peripheral neuropathy can lead to decreased sensation and increased risk of trauma. This measure helps prevent wounds, ulcers, and other complications. Applying a heating pad (Choice B) can worsen symptoms and cause burns due to decreased sensation. Keeping the client's feet elevated (Choice C) may help reduce swelling but does not directly address the risk of injury. Assessing for jaundice (Choice D) is important in cirrhosis but is not directly related to the client's risk of injury due to peripheral neuropathy.

5. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The PN notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

• A. Ask family members to remain with the client in the evenings from 5 to 8 pm
• B. Administer a prescribed PRN benzodiazepine at the onset of a confused state
• C. Ensure that the client is assigned to a room close to the nurses' station
• D. Postpone administration of nighttime medications until after 11 pm

Correct answer: C

Rationale: Sundowning, a phenomenon where dementia symptoms worsen in the evening, can be managed by ensuring the client is close to the nurses' station for frequent monitoring and quick intervention, if necessary. This reduces the risk of harm and helps manage agitation. Asking family members to remain with the client may not always be feasible and does not address the need for close monitoring. Administering benzodiazepines should not be the first-line intervention for sundowning as it can increase the risk of falls and other adverse effects. Postponing medication administration may disrupt the client's routine and potentially worsen symptoms.

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