Nursing Elites

1. What is the first exercise that should be performed by a client who had a mastectomy?

• A. Walking the hand up the wall
• B. Sweeping the floor
• C. Combing her hair
• D. Squeezing a ball

Correct answer: D

Rationale: The correct answer is D: Squeezing a ball. The first exercise that should be done by a client with a mastectomy is squeezing a ball. This helps in regaining strength and mobility in the affected area. Choices A, B, and C are incorrect as they are not typically the initial exercises recommended post-mastectomy. Walking the hand up the wall, sweeping the floor, and combing hair are activities that may be introduced later in the rehabilitation process.

2. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

• A. Assessment of the client's level of anxiety
• B. Evaluation of the client's exercise tolerance
• C. Identification of peripheral pulses
• D. Assessment of bowel sounds and activity

Correct answer: C

Rationale: The most crucial assessment during the preoperative period for a client with a sacular abdominal aortic aneurysm scheduled for surgical repair is the identification of peripheral pulses. During surgery, the aorta will be clamped, potentially affecting blood circulation to the kidneys and lower extremities. Therefore, it is essential for the nurse to assess peripheral pulses and monitor the return of circulation to the lower extremities postoperatively. Assessing the client's level of anxiety (Choice A) is important but not as crucial as ensuring adequate circulation. Evaluating exercise tolerance (Choice B) is not recommended preoperatively for this situation. Assessing bowel sounds and activity (Choice D) is of lesser concern compared to the critical need to monitor peripheral circulation.

3. The nurse is assessing an elder whom the nurse suspects is being physically abused. The most important question for the nurse to ask is:

• A. "How much money do you keep around the house?"?
• B. "Who provides your physical care?"?
• C. "How close does your nearest relative live?"?
• D. "What form of transportation do you use?"?

Correct answer: B

Rationale: The most important question for the nurse to ask when suspecting elder abuse is 'Who provides your physical care?' This question is crucial as the primary caregiver, who is often the abuser in cases of elder abuse, lives with the client. Research has shown that spouses and adult children are the most common abusers. By inquiring about the provider of physical care, the nurse can assess the potential abuser's proximity to the elder. Choices A, C, and D are less pertinent to identifying the primary caregiver, who is more likely to be the abuser.

4. A new nursing graduate indicates in charting entries that he is a licensed practical nurse, although he has not yet received the results of the licensing exam. The graduate's action can result in what type of charge?

• A. Fraud
• B. Tort
• C. Malpractice
• D. Negligence

Correct answer: A

Rationale: The correct answer is 'Fraud.' Identifying oneself as a nurse without a license defrauds the public and can lead to prosecution. A tort is a wrongful act in breach of a legal duty imposed by law; malpractice is the failure to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. In this scenario, the key issue is the misrepresentation of licensure status, which constitutes fraud. Therefore, choices B, C, and D are incorrect.

5. Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?

• A. 0.9% sodium chloride
• B. 5% dextrose in water solution
• C. Sterile water
• D. Heparin sodium

Correct answer: A

Rationale: The correct answer is 0.9% sodium chloride. Normal saline is 0.9% sodium chloride, which has the same osmolarity as blood and does not cause cell lysis. Choices 2 and 3, 5% dextrose in water solution and sterile water, are hypotonic solutions that can lead to cell lysis. Choice 4, Heparin sodium, is an anticoagulant and is not routinely used to flush an IV device before and after the administration of blood.

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