Nursing Elites

1. A nurse assisting with data collection plans to assess tactile (vocal) fremitus. The nurse performs this by using which technique?

• A. Palpating for symmetric chest expansion
• B. Auscultating the breath sounds over the trachea and larynx
• C. Auscultating the breath sounds over the peripheral lung fields
• D. Palpating the thorax, comparing vibrations from side to side as the client repeats the word 'ninety-nine'

Correct answer: D

Rationale: To assess tactile (vocal) fremitus, the nurse palpates the thorax and compares vibrations from side to side as the client repeats the word 'ninety-nine.' This technique helps in evaluating the intensity and symmetry of vibrations felt. Palpating for symmetric chest expansion involves assessing the expansion of the chest during breathing by placing hands on the anterolateral wall. Auscultating the breath sounds over the trachea and larynx is done to assess bronchial breath sounds, while auscultating over the peripheral lung fields is used to assess vesicular breath sounds.

2. If Ms. Barrett's distance vision is 20/30, which of the following statements is true?

• A. The client can read from 20' what a person with normal vision can read at 30'.
• B. The client can read from 30' what a person with normal vision can read at 20'.
• C. The client can read the entire chart from 30'.
• D. The client can read the chart from 20' with the left eye and from 30' with the right eye.

Correct answer: A

Rationale: When Ms. Barrett's distance vision is measured as 20/30, it means that she can read from 20 feet away what a person with normal vision can read at 30 feet. The numerator (20) represents the distance in feet between the chart and the client, while the denominator (30) indicates the distance at which a normal eye can read the chart. In this case, Ms. Barrett's vision is slightly worse than normal, as she needs to be closer to the chart to read it clearly. Therefore, choice A is correct. Choices B, C, and D are incorrect: Choice B reverses the distances, Choice C assumes the client can read the entire chart from 30 feet, and Choice D introduces information not related to the 20/30 measurement.

3. A nurse assisting with data collection is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note?

• A. Gurgling sounds
• B. Hypoactive sounds
• C. Low-pitched sounds
• D. An absence of sounds

Correct answer: A

Rationale: Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly between five and 30 times a minute. In this scenario, since the client ate lunch just 45 minutes ago, the nurse would expect to note gurgling sounds as normal bowel activity. Hypoactive sounds (low-pitched) or an absence of sounds are usually associated with conditions such as abdominal surgery or inflammation of the peritoneum, not with recent food intake. Therefore, the correct answer is gurgling sounds, indicating normal bowel activity following a recent meal.

4. A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant performs which action?

• A. Uses short sentences
• B. Speaks at a normal rate and volume
• C. Uses facial expressions or gestures
• D. Overarticulates words

Correct answer: D

Rationale: The correct answer is 'Overarticulates words.' When communicating with a hearing-impaired client who may rely on lip-reading, it is essential to speak clearly at a normal rate and volume. Overarticulating words can distort lip movements, making it harder for the client to understand. Using short sentences helps in conveying information effectively, allowing the client time to process. While facial expressions and gestures provide additional visual cues that aid in communication, overarticulating words can be counterproductive in this scenario. Therefore, the nursing assistant should avoid overarticulating words to ensure clear and concise communication for the client.

5. The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the LPN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?

• A. The LPN clarifies the severity of the Penicillin allergy.
• B. The LPN discusses the order with the care team prior to administering Cefazolin.
• C. The LPN administers all ordered medications except for the Cefazolin.
• D. The LPN monitors the client after a test dose of Cefazolin is administered.

Correct answer: C

Rationale: The least appropriate action is for the LPN to administer all ordered medications except for the Cefazolin. The LPN should always consider the client's documented allergy to Penicillin seriously. It is crucial to discuss the order with the care team before administering Cefazolin to ensure patient safety. Administering a medication that could potentially cause harm due to a documented allergy is unsafe practice. While monitoring the client after a test dose of Cefazolin is important, it should not precede clarification with the care team regarding the allergy and the appropriateness of the medication. Therefore, withholding the Cefazolin is the most appropriate action in this scenario.

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