Nursing Elites

1. When assessing a client with sinusitis, which technique should the nurse use to identify manifestations of this disorder?

• A. Percussion of the frontal sinuses
• B. Auscultation of the trachea
• C. Inspection of the nasal mucosa
• D. Palpation of the orbital areas

Correct answer: D

Rationale: Sinusitis is an inflammation of the sinus cavities, which can cause tenderness and pain around the eyes (orbital areas). Palpation of the orbital areas can help identify tenderness and swelling associated with sinusitis. Auscultation of the trachea and percussion of the frontal sinuses are not relevant assessment techniques for sinusitis. Inspection of the nasal mucosa may reveal signs of inflammation, but palpation of the orbital areas is a more direct method to assess for tenderness and swelling in this specific condition.

2. For a rectal examination, the patient can be directed to assume which of the following positions?

• A. Genupectoral
• B. Sims
• C. Horizontal recumbent
• D. All of the above

Correct answer: B

Rationale: The correct position for a rectal examination is the Sims position, where the patient lies on their left side with the upper knee flexed. This position allows for easy access and visualization of the rectal area for examination.

3. Which technique in physical examination is used to assess the movement of air through the tracheobronchial tree?

• A. Palpation
• B. Auscultation
• C. Inspection
• D. Percussion

Correct answer: B

Rationale: The correct answer is B: Auscultation. Auscultation is a technique in physical examination used to assess the movement of air through the tracheobronchial tree. During auscultation, healthcare providers listen to lung sounds using a stethoscope to detect abnormalities such as wheezing, crackles, or diminished breath sounds, which can indicate conditions affecting the airways or lungs. Palpation (Choice A) involves feeling the body for abnormalities, Inspection (Choice C) involves visual examination, and Percussion (Choice D) involves tapping on the body to produce sounds that can help in assessing underlying structures, but they are not directly used to assess air movement through the tracheobronchial tree.

4. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?

• A. Decreased blood pressure and heart rate and shallow respirations
• B. Quiet crying
• C. Immobility, diaphoresis, and avoidance of deep breathing or coughing
• D. Changing position every 2 hours

Correct answer: C

Rationale: Immobility, diaphoresis, and avoidance of deep breathing or coughing are common signs of pain.

5. A client with COPD expresses concerns about leaving the house due to continuous oxygen use. What is an appropriate response by the nurse?

• A. There are portable oxygen delivery systems that you can take with you.
• B. When you go out, you can remove the oxygen and then reapply it when you get home.
• C. You probably will not be able to go out as much as you used to.
• D. Home health services will come to see you so you will not need to get out.

Correct answer: A

Rationale: For a client with COPD concerned about leaving the house while on continuous oxygen, the nurse should provide reassurance by mentioning the availability of portable oxygen delivery systems. These systems allow the client to maintain their oxygen therapy while being mobile, enabling them to go out and engage in activities outside the home. This response promotes independence and quality of life for the client, addressing their immediate concerns and offering a practical solution to their perceived limitation.

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