Nursing Elites

1. When performing an abdominal assessment on a client, what action should the nurse take first?

• A. Palpate the abdomen
• B. Auscultate bowel sounds
• C. Inspect the abdomen
• D. Percuss the abdomen

Correct answer: B

Rationale: The correct answer is to auscultate bowel sounds. This action should be taken first because it ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen (choice C) may provide visual cues but does not address functional assessment. Palpating the abdomen (choice A) should follow auscultation to prevent altering bowel sounds. Percussing the abdomen (choice D) is typically done after auscultation and palpation.

2. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

• A. Frequent repositioning
• B. Poor nutrition
• C. Increased fluid intake
• D. Use of a special mattress

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

3. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. Which food should the nurse instruct the client to avoid?

• A. Steamed carrots
• B. Orange slices
• C. Mashed potatoes
• D. Baked chicken

Correct answer: B

Rationale: Correct! Orange slices should be avoided by clients on a mechanical soft diet as they can be difficult to chew and swallow. Steamed carrots, mashed potatoes, and baked chicken are suitable choices for a mechanical soft diet, as they are softer in texture and easier to consume without posing a risk of choking or swallowing difficulties.

4. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Administer antihypertensive medication
• B. Notify the healthcare provider
• C. Recheck the blood pressure
• D. Document the blood pressure in the chart

Correct answer: C

Rationale: The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.

5. A client with diabetes mellitus is being taught about foot care by a nurse. Which statement indicates understanding?

• A. I will soak my feet in hot water daily
• B. I will wear my slippers whenever I am out of bed
• C. I should apply lotion between my toes after washing my feet
• D. I will cut my nails in a rounded shape

Correct answer: B

Rationale: The correct answer is B. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it helps prevent injuries to the feet, reducing the risk of infection. Choices A, C, and D are incorrect. Soaking feet in hot water daily can lead to dryness and skin damage, applying lotion between toes can create a moist environment promoting fungal growth, and cutting nails in a rounded shape can increase the risk of ingrown nails.

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