Nursing Elites

1. During passive range of motion (ROM) exercises, how should the nurse perform each movement for a patient with impaired mobility?

• A. The nurse moves each movement just to the point of resistance.
• B. The patient repeats each movement 5 times.
• C. The movement continues until the patient reports pain.
• D. The nurse completes each movement quickly and smoothly.

Correct answer: A

Rationale: During passive range of motion (ROM) exercises, the nurse is responsible for moving the patient's joints through their range of motion. The correct technique involves performing movements slowly and smoothly, only going to the point of resistance without causing pain. This technique helps maintain joint flexibility and prevent contractures. Choice A is the correct answer as it reflects the appropriate technique for passive ROM exercises. Choices B and C are incorrect because the patient is not actively participating, and ROM exercises should not cause pain. Choice D is incorrect as movements should be done deliberately and not quickly.

2. During an eye assessment, what action should the nurse take to assess a client's extraocular eye movements?

• A. Position the client 6.1 m (20 ft) away from the Snellen chart
• B. Instruct the client to follow a finger through the six cardinal positions of gaze
• C. Ask the client to cover their right eye during assessment of the left eye
• D. Hold a finger 46 cm (18 inches) away from the client's eye

Correct answer: B

Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action to assess extraocular eye movements effectively. This technique evaluates the function of the six extraocular muscles and cranial nerves III, IV, and VI. Positioning the client 6.1 m away from the Snellen chart is more relevant for visual acuity testing. Asking the client to cover their right eye during the assessment is not necessary for evaluating extraocular movements. Holding a finger at a specific distance in front of the client's eye is not an appropriate method for assessing extraocular eye movements.

3. A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching?

• A. I can place an oval corn pad over toes that have corns as long as I remove the pad weekly
• B. I should soak my feet in warm water daily to soften corns and calluses
• C. I can apply lotion to soften calluses as long as I don’t put lotion between my toes
• D. I should use an over the counter liquid medication to remove corns

Correct answer: C

Rationale: Applying lotion to the feet, avoiding between toes, is correct; over-the-counter treatments and soaking are not recommended.

4. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

• A. Bounding pulse
• B. Decreased blood pressure
• C. Dry mucous membranes
• D. Weak pulse

Correct answer: A

Rationale: A bounding pulse is indicative of fluid volume excess. In this case, the client's weight gain and edematous ankles already suggest fluid volume overload. A bounding pulse occurs due to increased blood volume and pressure. Choices B, C, and D are not indicative of fluid volume excess. Decreased blood pressure, dry mucous membranes, and weak pulse are more commonly associated with conditions such as dehydration or hypovolemia, where there is a decrease in fluid volume rather than an excess.

5. In an emergency situation, the charge nurse on the night shift at an urgent care center has to deal with admitting clients of higher acuity than usual due to a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?

• A. Assume a decision-making role
• B. Seek input from staff
• C. Use a non-directive approach
• D. Shared decision-making with others

Correct answer: A

Rationale: In an emergency situation such as dealing with patients of higher acuity due to a large fire, it is crucial for the charge nurse to assume a decision-making role. This style of leadership allows for quick and efficient decision-making to manage the increased acuity of patients effectively. Seeking input from staff (Choice B) may delay critical decisions needed in emergencies. Using a non-directive approach (Choice C) or shared decision-making with others (Choice D) may not be suitable in urgent situations where immediate actions are required to address the high acuity of patients.

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