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. A client with stage IV lung cancer is 3 days postoperative following a wedge resection. The client states, “I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child’s wedding.” Based on the Kubler-Ross model, which stage of grief is the client experiencing?

• A. Anger
• B. Denial
• C. Bargaining
• D. Acceptance

Correct answer: C

Rationale: The client is in the bargaining stage of grief according to the Kubler-Ross model. In this stage, individuals negotiate for more time to achieve specific goals or fulfill desires. The client's statement about quitting smoking to attend their child's wedding reflects this bargaining behavior. Anger (choice A) is characterized by frustration and resentment, denial (choice B) involves avoidance of reality, and acceptance (choice D) signifies coming to terms with the situation, none of which align with the client's current mindset of bargaining.

3. A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?

• A. “I will place the client on their side.”
• B. “I will go to the nurses’ station for assistance.”
• C. “I will note the time that the seizure begins.”
• D. “I will prepare to insert an airway.”

Correct answer: B

Rationale: The correct answer is B. Going to the nurses’ station for assistance during a seizure is inappropriate as immediate care is necessary. Placing the client on their side helps maintain an open airway and prevents aspiration. Noting the time the seizure begins is crucial for monitoring and documentation. Preparing to insert an airway may be necessary if the client's airway becomes compromised. Therefore, the nurse's statement about going to the nurses' station for assistance is the only incorrect response as it delays essential care.

4. A client with a diagnosis of hypertension is being assessed. Which symptom would be most concerning?

• A. Headache
• B. Blurred vision
• C. Dizziness
• D. Chest pain

Correct answer: D

Rationale: Chest pain in a client with hypertension is the most concerning symptom as it may indicate a myocardial infarction or other serious cardiac event related to hypertension. Immediate intervention is required to address potential life-threatening conditions. Headache, blurred vision, and dizziness are common symptoms associated with hypertension but are not typically indicative of an acute cardiac event requiring urgent attention.

5. A client with a history of asthma is experiencing shortness of breath. What is the most appropriate action for the LPN/LVN to take first?

• A. Administer a bronchodilator as prescribed.
• B. Encourage the client to practice deep breathing exercises.
• C. Position the client in high Fowler's position.
• D. Obtain a peak flow reading.

Correct answer: A

Rationale: Administering a bronchodilator as prescribed is the most appropriate initial action for managing asthma-related shortness of breath. Bronchodilators help to open up the airways quickly, providing relief for the client. Encouraging deep breathing exercises may be beneficial in some situations but should not be the first action for acute shortness of breath in asthma. Positioning the client in high Fowler's position can also help improve breathing, but administering the bronchodilator takes precedence. Obtaining a peak flow reading is important in asthma management, but it is not the initial action needed to address acute shortness of breath.

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