Nursing Elites

1. A nurse enters the hospital room of a client with reduced immunity. What observation requires further action by the nurse?

• A. The client is in a private room.
• B. The client has a vase of fresh flowers on the table
• C. The client has a dedicated vital signs machine
• D. There is hand sanitizer by the door

Correct answer: B

Rationale:

2. The medical record for a client states that the client has hemiplegia. What does this mean?

• A. The client can use his right arm, left leg, and left arm.
• B. The client has paralysis of all four extremities.
• C. The client has decreased vision in one eye.
• D. The client has paralysis on one side of the body.

Correct answer: D

Rationale: Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.

3. What is the best nursing intervention for a client with limited mobility who cannot move independently?

• A. Passive range of motion
• B. Pillows for positioning
• C. Active range of motion
• D. Continuous passive motion

Correct answer: A

Rationale: The best nursing intervention for a client with limited mobility who cannot move independently is passive range of motion. Passive range of motion exercises help maintain joint flexibility, prevent contractures, and improve circulation in immobile clients. Choice B, pillows for positioning, may provide comfort but does not address the need for joint movement. Choice C, active range of motion, requires the client's active participation, which is not feasible for someone with limited mobility. Choice D, continuous passive motion, is more commonly used in rehabilitation settings for specific joints and is not typically the primary intervention for overall limited mobility.

4. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?

• A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
• B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
• C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
• D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'

Correct answer: A

Rationale:

5. A nurse is caring for an immobile client. What is the priority assessment of this client?

• A. Palpate for edema
• B. Auscultate for bowel sounds
• C. Inspect the skin for injury
• D. Auscultation of lung sounds

Correct answer: C

Rationale: Inspecting the skin for injury is crucial to prevent pressure ulcers and other complications in immobile clients.

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