Nursing Elites

1. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?

• A. Hand rolls
• B. A foot cradle
• C. A trapeze bar
• D. A trochanter roll

Correct answer: B

Rationale: A foot cradle is the correct choice for this situation. A foot cradle is used to reduce pressure on the tips of a patient's toes in individuals with poor lower extremity circulation. Hand rolls are not designed to address toe irritation specifically. A trapeze bar is used to assist patients with repositioning in bed, and a trochanter roll is used to support the hips and prevent external rotation of the legs, neither of which directly address toe irritation in this scenario.

2. Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?

• A. Insert an indwelling urinary catheter.
• B. Limit caloric and protein intake.
• C. Turn the patient every 2 hours.
• D. Assess for pain during a bath.

Correct answer: D

Rationale: The most important action for preventing skin impairment in a mobile patient with local nerve damage is to assess for pain during a bath. Assessing pain during a bath helps in evaluating sensory nerve function by checking for touch, pain, heat, cold, and pressure. This assessment is crucial in identifying areas of potential skin breakdown and implementing preventive measures. Inserting an indwelling urinary catheter (Choice A) is not directly related to preventing skin impairment in this context. Limiting caloric and protein intake (Choice B) is not pertinent to skin impairment prevention for a mobile patient with local nerve damage. While turning the patient every 2 hours (Choice C) is a good practice for preventing pressure ulcers, in this case, assessing for pain during a bath is more directly related to preventing skin impairment associated with nerve damage.

3. A client who is postoperative has paralytic ileus. Which of the following abdominal assessments should the nurse expect?

• A. Absent bowel sounds with distention
• B. Hyperactive bowel sounds with pain
• C. Normal bowel sounds with cramping
• D. Diminished bowel sounds with tenderness

Correct answer: A

Rationale: Paralytic ileus is a condition where there is a temporary paralysis of the bowel, leading to absent bowel sounds and abdominal distention. This occurs because the bowel is not functioning properly to propel contents, resulting in a lack of bowel sounds. Absent bowel sounds with distention are typical findings in paralytic ileus. Hyperactive bowel sounds with pain are more indicative of increased motility and are not expected in paralytic ileus. Normal bowel sounds with cramping may be seen in other conditions, such as gastroenteritis. Diminished bowel sounds with tenderness are not typical findings in paralytic ileus.

4. The client has been diagnosed with deep vein thrombosis (DVT). Which symptom would be most concerning?

• A. Pain in the affected leg
• B. Redness and warmth in the affected leg
• C. Shortness of breath
• D. Swelling in the affected leg

Correct answer: C

Rationale: Shortness of breath is the most concerning symptom in a client with deep vein thrombosis (DVT) because it could indicate a pulmonary embolism, a life-threatening complication where a blood clot travels to the lungs. This condition requires immediate medical attention. While pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT, shortness of breath suggests a more critical situation that necessitates urgent intervention.

5. A healthcare professional is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the healthcare professional provide to the assistive personnel?

• A. Collect at least 2 inches of formed stool.
• B. Wear sterile gloves while obtaining the specimen.
• C. Use a culturette for specimen collection.
• D. Record the date and time the stool was collected.

Correct answer: A

Rationale: To ensure accurate testing, a minimum amount of stool is required for specimen collection, typically at least 2 inches of formed stool. This amount provides an adequate sample for testing. Wearing sterile gloves is important for infection control but is not specifically required for stool specimen collection. Using a culturette is not typically necessary for collecting stool specimens. Recording the date and time the stool was collected is essential to ensure timely processing but does not directly impact the collection of the specimen itself.

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