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 preparing to transfer a client from a bed to a chair. The client can bear partial weight and has upper body strength. What device should the nurse use?

• A. Mechanical lift
• B. Gait belt
• C. Slide board
• D. Stand-assist lift

Correct answer: D

Rationale: A stand-assist lift is the correct choice in this scenario. This device is suitable for clients who can bear partial weight and have upper body strength, as it allows them to actively participate in the transfer process. A mechanical lift is typically used for clients who are non-weight bearing or have limited mobility. A gait belt is used for providing support and stability during walking or transferring short distances. A slide board is used for transferring clients who are unable to bear weight and need assistance moving from one surface to another.

3. A nurse is caring for a client who is undergoing surgery for a hip fracture. What is a priority intervention to reduce the risk of postoperative complications?

• A. Encourage early ambulation
• B. Provide intravenous antibiotics
• C. Apply anti-embolism stockings
• D. Place a Foley catheter to monitor output

Correct answer: A

Rationale: Encouraging early ambulation is crucial in reducing the risk of postoperative complications, such as blood clots and pneumonia. Early mobilization helps prevent complications like deep vein thrombosis and pneumonia by promoting circulation and preventing respiratory complications. Providing intravenous antibiotics (Choice B) is important for preventing infections but is not the priority immediately post-surgery. Applying anti-embolism stockings (Choice C) is beneficial in preventing venous thromboembolism but does not address the immediate need for mobility. Placing a Foley catheter (Choice D) may be necessary during surgery but is not a priority intervention to reduce postoperative complications related to immobility.

4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?

• A. Natural immunity
• B. Acquired immunity
• C. Passive immunity
• D. Cell-mediated immunity

Correct answer: B

Rationale: An immunization functions as part of acquired immunity. Acquired immunity involves the production of antibodies after immunization, which helps protect against future infections. Natural immunity is not induced by immunization but is present from birth. Passive immunity is temporary and acquired through the transfer of pre-formed antibodies. Cell-mediated immunity is a type of immune response that involves the activation of phagocytes, antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen.

5. A healthcare professional is teaching a group of assistive personnel about the expected integumentary changes in older adults. Which change should the healthcare professional include?

• A. Increase in skin turgor
• B. Increase in subcutaneous fat
• C. Decrease in moisture levels
• D. Increase in oil production

Correct answer: C

Rationale: The correct answer is C: Decrease in moisture levels. In older adults, there is a reduction in oil production, leading to decreased moisture levels in the skin. This change can result in dry skin and increased risk of skin issues. The other choices are incorrect because in older adults, skin turgor tends to decrease, subcutaneous fat may decrease, and oil production typically decreases rather than increases.

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