Nursing Elites

1. You are working the 4 pm to 12 midnight evening shift. You are taking care of a group of patients. The supervising RN identifies 5 patients who get a medication at 'HS'. When will you give this medication?

• A. After the dinner meal
• B. Whenever requested
• C. At the patient's bedtime
• D. Before the end of the shift

Correct answer: C

Rationale: The correct answer is to give the medication at the patient's bedtime. 'HS' is a medical abbreviation that stands for 'hora somni,' which translates to 'at bedtime' or 'at the hours of sleep.' This timing ensures that the medication is administered appropriately to align with the patient's sleep schedule and maximize its effectiveness. Choices A, B, and D are incorrect because giving the medication after dinner, whenever requested, or before the end of the shift may not coincide with the intended purpose of the medication, potentially affecting its efficacy and patient outcomes.

2. When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?

• A. When the infant is sleeping
• B. At the end of the examination
• C. Before auscultation of the thorax
• D. At about the middle of the examination

Correct answer: B

Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress. Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.

3. A client is undergoing range of motion exercises, and the nurse moves the leg in a pattern of circumduction. Which movement is the nurse performing?

• A. Bending the leg at the knee
• B. Turning the foot inward and outward
• C. Moving the leg in a circle
• D. Moving the leg forward and up

Correct answer: C

Rationale: Circumduction involves moving a limb in a circular pattern. In this scenario, the nurse is performing circumduction by moving the leg in a circular motion, engaging the muscles of the gluteus maximus and gluteus medius. Choice A, 'Bending the leg at the knee,' is incorrect as it describes flexion and extension movements. Choice B, 'Turning the foot inward and outward,' refers to inversion and eversion movements of the foot, not circumduction. Choice D, 'Moving the leg forward and up,' describes flexion and abduction movements, not circumduction.

4. A healthcare professional is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?

• A. Patient who is receiving chemotherapy for liver cancer
• B. Patient who is receiving chemotherapy for lung cancer
• C. Patient who has a wound infection after cholecystectomy
• D. Patient who requires pain management for chronic pancreatitis

Correct answer: D

Rationale: The patient with chronic pancreatitis is the best choice to admit to the same room as a patient who had a liver transplant and is experiencing acute rejection. This is because the patient with chronic pancreatitis does not pose an infection risk to the immunosuppressed patient who had a liver transplant. On the other hand, patients receiving chemotherapy for cancer or those with wound infections are at risk for infections, which could endanger the immunosuppressed patient with acute rejection.

5. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

• A. Listen to a patient's lung sounds for wheezes or rhonchi.
• B. Label specimens obtained during percutaneous lung biopsy.
• C. Instruct a patient about how to use home spirometry testing.
• D. Measure induration at the site of a patient's intradermal skin test.

Correct answer: B

Rationale: Labeling specimens obtained during a percutaneous lung biopsy is a task that can be appropriately delegated to unlicensed assistive personnel (UAP) as it does not require nursing judgment. UAP can perform this task safely under the supervision of a nurse. Listening to a patient's lung sounds for wheezes or rhonchi, instructing a patient about how to use home spirometry testing, and measuring induration at the site of a patient's intradermal skin test all require nursing judgment and interpretation of findings. These tasks should be performed by licensed nursing personnel to ensure accurate assessment and appropriate intervention.

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