Nursing Elites

1. While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?

• A. Document the finding
• B. Palpate the area for a mass
• C. Notify the healthcare provider
• D. Percuss the abdomen to check for tympany

Correct answer: C

Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.

2. 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.

3. What is the primary force in sex education in a child's life?

• A. school nurse
• B. peers
• C. parents
• D. media

Correct answer: C

Rationale: Parents are the primary force in sex education in a child's life. Parents play a central role in shaping a child's understanding of sex from an early age. They provide continuous guidance, values, and information about sex and relationships. While the school nurse is involved in formal sex education and counseling within the school setting, parents have the most direct and significant impact on a child's sex education. Peers become more influential during adolescence, but their information may not always be accurate or appropriate. The media also exert significant influence on children's perceptions of sex through various forms of entertainment like movies, TV shows, and video games, but parents remain the primary educators on this subject.

4. A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?

• A. a banana
• B. grapefruit
• C. a salami sandwich
• D. avocado slices

Correct answer: B

Rationale: The correct answer is grapefruit. Clients taking MAO Inhibitors like phenelzine (Nardil) should avoid foods rich in tyramine to prevent hypertensive crisis. Grapefruit is a suitable choice as it is not high in tyramine. Bananas, avocados, and salami are foods that should be avoided due to their tyramine content, which can interact adversely with MAO Inhibitors. Therefore, choosing grapefruit is the safest option for the client.

5. The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

• A. The client should remove all scatter rugs from the floor and minimize clutter.
• B. The client should not limit her movement within the home unless advised by the physician.
• C. The client should have a raised toilet seat and grab bars available in the bathroom.
• D. The client should not wear a robe and socks while walking in the house.

Correct answer: A

Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.

Similar Questions