Nursing Elites

1. When assessing a client with a small bowel obstruction, what finding should a nurse expect?

• A. Significant abdominal distention
• B. Large bowel movements
• C. High-pitched bowel sounds
• D. Copious vomiting

Correct answer: C

Rationale: High-pitched bowel sounds are often heard early in a small bowel obstruction due to increased peristalsis as the bowel tries to overcome the blockage. Choices A, B, and D are incorrect. Abdominal distention is more commonly associated with large bowel obstructions, while large bowel movements and copious vomiting are not typical findings in small bowel obstructions.

2. A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvic organ prolapse. What exercise will the client need to perform?

• A. Kegel exercises
• B. Isometric exercises
• C. Circumduction exercises
• D. Uterine extension exercises

Correct answer: A

Rationale: Corrected Rationale: The client with a cystocele should perform Kegel exercises to strengthen the pelvic floor muscles, reducing the risk of pelvic organ prolapse and stress urinary incontinence. Kegel exercises specifically target the muscles that support the pelvic organs. Isometric exercises focus on static muscle contractions and may not be as effective as Kegel exercises for strengthening the pelvic floor. Circumduction exercises involve circular movements at joints and are not specific to pelvic floor muscle strengthening. Uterine extension exercises do not directly target the pelvic floor muscles and are not indicated for cystocele management.

3. A nurse is caring for a patient whose family member requests to view the patient’s medical record. What response should the nurse make?

• A. “The patient should provide permission to share the records with you.”
• B. “You can view the records if the provider approves it.”
• C. “I will allow you to see the chart if the patient is unable to give consent.”
• D. “You need to fill out a request form.”

Correct answer: A

Rationale: In this scenario, the nurse should respond by indicating that the patient needs to provide permission to share their medical records with the family member. Patient confidentiality is a fundamental principle in healthcare, and sharing medical records without the patient's consent is a violation of privacy. Choice B is incorrect because the provider's approval alone is not sufficient to share medical records, as patient consent is crucial. Choice C is incorrect because viewing the patient's chart without the patient's consent is not appropriate. Choice D is incorrect as filling out a request form does not address the issue of patient consent, which is essential for sharing medical information.

4. A client in respiratory distress who is on oxygen is being cared for by a nurse. What is the most appropriate short-term goal?

• A. Nasal cannula remains in place
• B. Client completes morning care
• C. Client verbalizes breathing improvement after lunch
• D. Client maintains oxygen saturation of 90% during the shift

Correct answer: D

Rationale: The correct answer is D because maintaining oxygen saturation of 90% is a specific, measurable short-term goal that ensures adequate oxygenation. Choice A is not a goal focused on the client's physiological status but rather on the equipment. Choice B is related to activities of daily living and does not address the respiratory distress issue. Choice C is subjective and may not reflect the actual physiological improvement in the client's condition.

5. While assessing four clients, which client data should be reported to the provider?

• A. Client with pleurisy who reports a pain level of 6 out of 10 when coughing
• B. Client with 110 mL of serosanguineous fluid from a JP drain
• C. Client 4 hours postoperative with a heart rate of 98 bpm
• D. Client undergoing chemotherapy with an absolute neutrophil count of 75/mm³

Correct answer: D

Rationale: An absolute neutrophil count of 75/mm³ is critically low and places the client at high risk for infection, necessitating immediate intervention. Neutropenia increases susceptibility to infections, making it essential to report this finding promptly. The other options, such as pain level in pleurisy, drainage amount from a drain, and heart rate postoperatively, are important but do not indicate an immediate life-threatening condition that requires urgent provider notification.

Similar Questions