Nursing Elites

1. The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?

• A. Performing ROM exercises during bathing.
• B. Changing the patient's position every two hours.
• C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
• D. Placing the patient in the prone position for one hour three times a day.

Correct answer: C

Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.

2. A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?

• A. Refer to the risk manager
• B. Notify the healthcare provider
• C. Discontinue the ventilator
• D. Review the medical record

Correct answer: B

Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.

3. The healthcare provider is teaching a client with hypertension about lifestyle modifications. Which instruction should the healthcare provider include?

• A. Limit sodium intake to 2,300 mg per day
• B. Engage in moderate exercise for 30 minutes daily
• C. Consume a diet high in saturated fats
• D. Avoid alcohol consumption completely

Correct answer: B

Rationale: Engaging in moderate exercise for 30 minutes daily is a crucial lifestyle modification for managing hypertension. Regular physical activity helps lower blood pressure, improve cardiovascular health, and overall well-being. It is recommended to engage in activities like brisk walking, cycling, or swimming to achieve these benefits. Choices A, C, and D are incorrect. Limiting sodium intake, avoiding a diet high in saturated fats, and reducing alcohol consumption are also important lifestyle modifications for hypertension management, but engaging in moderate exercise is the most appropriate initial instruction for this client.

4. The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)

• A. 0.8 mL
• B. 0.75 mL
• C. 0.7 mL
• D. 0.9 mL

Correct answer: A

Rationale: To calculate the mL to administer, divide the ordered dose (3 mg) by the concentration (4 mg/mL). 3 mg ÷ 4 mg/mL = 0.75 mL. Rounding to the nearest tenth, the correct dose to administer is 0.8 mL.

5. A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the nurse implement first?

• A. Administer oxygen via non-rebreather mask.
• B. Administer furosemide (Lasix) IV push.
• C. Insert a Foley catheter to monitor urine output.
• D. Position the client in a high Fowler's position.

Correct answer: A

Rationale: Administering oxygen via a non-rebreather mask is the priority intervention for a client with pulmonary edema to improve oxygenation and address respiratory distress. Adequate oxygenation is essential to support vital organ function. Administering furosemide intravenously, inserting a Foley catheter to monitor urine output, and positioning the client in a high Fowler's position are important interventions but are secondary to ensuring optimal oxygenation in this client with pulmonary edema.

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