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. At what age are yearly mammograms recommended to start?

• A. Yearly mammograms are recommended starting at age 25.
• B. Yearly mammograms are recommended starting at age 40.
• C. Yearly mammograms are not necessary unless there is a family history of breast cancer.
• D. Yearly mammograms are recommended starting at age 20 and continuing until menopause begins.

Correct answer: B

Rationale: The correct answer is B. The American Cancer Society recommends yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Clinical breast examination should be done about every 3 years for women in their 20s and 30s and every year for women age 40 and older. Women should know how their breasts normally look and feel and report any breast change promptly to the healthcare provider. Breast self-examination should be done monthly starting when a woman is in her 20s. Choice A is incorrect as mammograms are not recommended to start at age 25. Choice C is incorrect as yearly mammograms are still recommended even without a family history of breast cancer. Choice D is incorrect as the recommended age for starting yearly mammograms is 40, not 20.

3. The nurse, assisting with data collection of the abdomen, inspects the client’s abdomen. Which assessment technique should the nurse perform next?

• A. Percussion
• B. Auscultation
• C. Light palpation
• D. Deep palpation

Correct answer: B

Rationale: The correct answer is auscultation. The assessment techniques used for a physical examination are inspection, palpation, percussion, and auscultation. These techniques are normally performed in this order. However, in the abdominal examination, auscultation is performed after inspection and before palpation and percussion. This order is specific to the abdomen because palpation and percussion can increase peristalsis, leading to a false interpretation of bowel sounds. Therefore, auscultation is performed before palpation and percussion in abdominal assessments to ensure accurate bowel sound assessment. Percussion and palpation are performed after auscultation in abdominal assessments. Choices A, C, and D are incorrect as auscultation is the next assessment technique to perform after inspection in abdominal assessments, followed by palpation and percussion.

4. A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope on which part of the client's chest?

• A. Second left interspace
• B. Second right interspace
• C. Left lower sternal border
• D. Fifth left interspace at the midclavicular line

Correct answer: D

Rationale: The correct placement for auscultating the apical heart rate in the area of the mitral valve is the fifth left interspace at the midclavicular line. Placing the stethoscope in the second left interspace would be to listen to the pulmonic valve, the second right interspace is for the aortic valve, and the left lower sternal border is for the tricuspid valve.

5. Which of the following vaccines contains a live virus?

• A. varicella
• B. IPV
• C. DTaP
• D. hepatitis B

Correct answer: A

Rationale: The correct answer is varicella. Varicella vaccine contains a live, weakened form of the varicella-zoster virus. Choice B, IPV (inactivated poliovirus vaccine), is an inactivated vaccine, not a live virus vaccine. Choices C and D, DTaP (diphtheria, tetanus, and acellular pertussis vaccine) and hepatitis B vaccine, respectively, do not contain live viruses. Varicella is the only live virus vaccine among the options.

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