Nursing Elites

1. The healthcare provider is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the healthcare provider use to help prevent injury secondary to this rotation?

• A. Hand rolls
• B. A trapeze bar
• C. A trochanter roll
• D. Hand-wrist splints

Correct answer: C

Rationale: A trochanter roll is the correct choice as it is used to prevent external rotation of the hips when the patient is in a supine position. Hand rolls (Choice A) are incorrect because they are used to prevent contractures of the fingers, wrist, and hand. A trapeze bar (Choice B) is not the correct option as it helps patients change positions in bed and aids with movement, not specifically for hip rotation. Hand-wrist splints (Choice D) are also incorrect as they are used to maintain the functional position of the wrist and hand, not to address hip rotation.

2. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?

• A. Lymphedema and nerve palsy
• B. Hearing loss and ataxia
• C. Headaches and vomiting
• D. Abdominal mass and weakness

Correct answer: D

Rationale: The correct answer is D: Abdominal mass and weakness. In neuroblastoma, the most common presenting signs are related to the mass effect of the tumor, leading to an abdominal mass and symptoms of weakness. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more indicative of other conditions like neurofibromatosis or brain tumors. Headaches and vomiting (Choice C) are more commonly seen in conditions such as brain tumors or increased intracranial pressure, but they are not specific to neuroblastoma.

3. When assessing a client's IV for infiltration, which finding would be unexpected for the nurse?

• A. The area around the infusion site feels warm to the touch.
• B. The infusion site is swollen and cool to the touch.
• C. The infusion line does not flush properly.
• D. There is no blood return in the infusion line.

Correct answer: A

Rationale: The correct answer is A. Warmth around the infusion site is not an expected finding with infiltration. Infiltration typically presents with swelling and coolness due to the fluid leaking into the surrounding tissue. Choices B, C, and D are incorrect because swelling, coolness, and difficulty flushing the line, as well as lack of blood return, are commonly associated with infiltration.

4. During an assessment, a healthcare professional is evaluating a client who has been on bed rest for the past month. Which of the following findings should the healthcare professional identify as an indication that the client has developed thrombophlebitis?

• A. bladder distention
• B. decreased blood pressure
• C. calf swelling
• D. diminished bowel sounds

Correct answer: C

Rationale: Calf swelling, redness, and tenderness are classic signs of thrombophlebitis. The swelling occurs due to the formation of a blood clot in the deep veins of the calf, leading to inflammation and potential obstruction of blood flow. Bladder distention (Choice A) is more indicative of urinary retention, decreased blood pressure (Choice B) can be seen in conditions like shock, and diminished bowel sounds (Choice D) may suggest gastrointestinal issues, none of which are directly related to thrombophlebitis.

5. The LPN/LVN mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?

• A. 31 gtt/min.
• B. 62 gtt/min.
• C. 93 gtt/min.
• D. 124 gtt/min.

Correct answer: D

Rationale: To calculate the drops per minute for the client, first, convert the weight from pounds to kilograms by dividing 182 by 2.2, which equals 82.72 kg. Then, calculate the dose in mcg/min by multiplying the weight in kg by the rate (82.72 kg * 5 mcg/kg/min = 413.6 mcg/min). Next, convert 50 mg to mcg (50 mg * 1000 = 50,000 mcg). Divide the total mcg (50,000 mcg) by the dose per minute (413.6 mcg/min) to get approximately 121 gtt/min. However, since the drip factor is 60 gtt/ml, the correct answer is 124 gtt/min, ensuring the accurate administration rate of the medication. Therefore, choice 'D' is the correct answer. Choices 'A', 'B', and 'C' are incorrect as they do not accurately reflect the calculated drops per minute based on the given information.

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