Nursing Elites

1. A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?

• A. Homan sign
• B. Murphy sign
• C. Blumberg sign
• D. McBurney sign

Correct answer: B

Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.

2. When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?

• A. nausea and vomiting
• B. itching
• C. urinary retention
• D. somnolence

Correct answer: B

Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. While urinary retention is a side effect of postpartum epidural morphine, it is not typically assessed within the first 3 hours. Somnolence is a rare side effect and not commonly observed within the first 3 hours. Therefore, itching is the most likely side effect to be observed within the initial 3 hours after administering postpartum epidural morphine.

3. A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should perform which action?

• A. Brush and floss their teeth after meals and at bedtime
• B. Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime
• C. Brush their teeth every morning and at bedtime
• D. Brush and floss their teeth every morning and at bedtime

Correct answer: A

Rationale: School-age children are capable of taking responsibility for their own dental hygiene. Establishing good oral health habits during childhood can lead to a lifetime of cavity prevention. The nurse advises the parents that their children should brush with fluoride toothpaste and floss between their teeth after meals and before bedtime. This routine helps maintain good oral health and teaches children the importance of dental care. Choice A is the correct answer as it emphasizes both brushing and flossing after meals and at bedtime, which are crucial for effective dental care. Choices B, C, and D are incorrect as they do not stress the significance of both brushing and flossing after meals, which is essential for proper oral hygiene.

4. When assisting the physician in performing transillumination of a client's scrotum, how should the nurse prepare for this procedure?

• A. Obtaining a flashlight and darkening the room
• B. Instructing the client to drink three glasses of water
• C. Instructing the client to take several deep breaths and bear down
• D. Telling the client that the procedure is very uncomfortable but that the discomfort will only last for a few moments

Correct answer: A

Rationale: When preparing for transillumination of the scrotum, the nurse should obtain a flashlight and darken the room. This is done to allow the strong flashlight to be shined from behind the scrotal contents. Normal scrotal contents do not appear on transillumination. Instructing the client to drink fluids or to take deep breaths and bear down is not part of the preparation for this procedure. Additionally, it is not necessary to inform the client that the procedure is uncomfortable as transillumination is a painless procedure.

5. Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:

• A. tolerance.
• B. constipation.
• C. sedation.
• D. addiction.

Correct answer: D

Rationale: The correct answer is 'addiction.' When caring for clients with cancer who are taking opioids, nurses need to assess for tolerance, constipation, and sedation as these are common side effects of opioid use. Addiction is not a primary concern when managing pain in terminally ill clients, as the goal is effective pain management rather than addiction prevention. Tolerance refers to the body's adaptation to the opioid over time, requiring higher doses for the same effect. Constipation and sedation are common side effects of opioids that nurses need to monitor and manage. Addiction is not a major concern in this population as the focus is on providing comfort and pain relief.

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