Nursing Elites

1. The LPN/LVN is assisting with the care of a client who has had a stroke. Which intervention is most important to include in the client's plan of care to prevent joint contractures?

• A. Encourage the client to perform active range-of-motion exercises.
• B. Use pillows to keep the client's extremities in a functional position.
• C. Place the client in a prone position for 30 minutes each day.
• D. Perform passive range-of-motion exercises on the affected side.

Correct answer: B

Rationale: Using pillows to keep the client's extremities in a functional position is crucial in preventing joint contractures. This intervention helps maintain proper alignment of the joints and reduces the risk of contractures by preventing prolonged positioning that can lead to muscle shortening. Encouraging the client to perform active range-of-motion exercises (Choice A) is beneficial for maintaining mobility but may not be the most important intervention to prevent joint contractures. Placing the client in a prone position for 30 minutes each day (Choice C) can be helpful for preventing pressure ulcers but is not directly related to preventing joint contractures. Performing passive range-of-motion exercises on the affected side (Choice D) can aid in maintaining joint flexibility but may not be as crucial as using pillows to prevent joint contractures.

2. A client is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?

• A. Administer antihypertensives as prescribed.
• B. Check the client’s weight daily.
• C. Notify the provider if the urine output is less than 30 mL/hr.
• D. Encourage the client to ambulate independently four times a day.

Correct answer: B

Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.

3. A client is immobile due to a cast, and a nurse is assisting in the use of a fracture bedpan. Which of the following actions should the nurse take?

• A. Place the shallow end of the fracture pan under the client’s buttocks.
• B. Encourage the client to remain immobile on the fracture pan for 20 minutes.
• C. Keep the bed flat while the client is on the fracture pan.
• D. Hyperextend the client’s back while the fracture pan is in place.

Correct answer: A

Rationale: The correct action when using a fracture bedpan for an immobile client is to place the shallow end of the pan under the client's buttocks. This positioning helps in proper collection of feces without causing discomfort or injury. Encouraging the client to try to defecate for 20 minutes (Choice B) is inappropriate and unrealistic, as defecation should not be forced or timed. Keeping the bed flat (Choice C) is incorrect as elevating the head of the bed can help promote proper positioning for bedpan use. Hyperextending the client's back (Choice D) is contraindicated and can lead to discomfort and potential injury to the client.

4. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the nurse include?

• A. “Use full-length side rails on the client’s bed.”
• B. “Check on the client frequently while they are in the restroom.”
• C. “Encourage physical activity throughout the day to expend energy.”
• D. “Remove clocks from the client’s room.”

Correct answer: C

Rationale: Encouraging physical activity is an effective non-restraint intervention for managing confused clients. It helps reduce agitation, promotes circulation, and may decrease the need for restraints. Choice A is incorrect as using full-length side rails can potentially restrict a client's movement, which is counterproductive to avoiding restraints. Choice B, while emphasizing monitoring, does not directly address alternatives to restraint use. Choice D is also incorrect as removing clocks from the client's room does not directly address managing confusion and reducing the need for restraints.

5. During the physical assessment of a client, which technique should a nurse use when performing a Romberg's test?

• A. Touch the client's face with a cotton ball
• B. Apply a vibrating tuning fork to the client's forehead
• C. Have the client stand with arms at her sides and feet together
• D. Perform direct percussion over the area of the kidneys

Correct answer: C

Rationale: During a Romberg's test, the nurse assesses the client's balance. Having the client stand with arms at her sides and feet together is the correct technique. This position helps the nurse observe for swaying or loss of balance, indicating alterations in balance. Choices A and B are incorrect as they are not part of Romberg's test and do not assess balance. Choice D is also incorrect as direct percussion over the kidneys is not associated with a Romberg's test.

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