Nursing Elites

1. During an abdominal assessment, what is the correct sequence of steps for a healthcare provider to follow?

• A. Inspection, percussion, palpation, auscultation
• B. Percussion, auscultation, inspection, palpation
• C. Auscultation, palpation, inspection, percussion
• D. Inspection, auscultation, percussion, palpation

Correct answer: D

Rationale: During an abdominal assessment, the correct sequence of steps is inspection, auscultation, percussion, and palpation. This sequence is followed to prevent altering bowel sounds. Inspection allows for visual observation, followed by auscultation to listen for bowel sounds without causing disturbance, percussion to assess for tympany or dullness, and finally palpation to feel for any abnormalities or tenderness. Choice A is incorrect because palpation should come after percussion. Choice B is incorrect as auscultation should be performed after inspection. Choice C is incorrect because palpation should be the final step after percussion.

2. A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following interventions should the healthcare provider include?

• A. Massage the ulcer
• B. Apply a heating pad
• C. Reposition the client every 2 hours
• D. Use alcohol-based cleansers

Correct answer: C

Rationale: Repositioning the client every 2 hours is a crucial intervention in the management of pressure ulcers. This action helps redistribute pressure, reducing the risk of further skin breakdown and promoting wound healing. Massaging the ulcer can cause further damage to the skin and underlying tissues. Applying a heating pad can increase the risk of skin breakdown and should be avoided. Alcohol-based cleansers are too harsh for pressure ulcers and can irritate the skin, potentially delaying healing.

3. A client has a new diagnosis of osteoarthritis and is being taught about dietary management. Which of the following statements should be included in the teaching?

• A. Increase your intake of calcium-rich foods.
• B. Avoid foods that are high in potassium.
• C. Increase your intake of vitamin D-rich foods.
• D. Avoid foods that are high in sodium.

Correct answer: C

Rationale: The correct statement to include in the teaching is to increase the intake of vitamin D-rich foods. Vitamin D helps improve calcium absorption, which is beneficial for bone health and may help alleviate symptoms of osteoarthritis. Option A is incorrect because while calcium is important for bone health, the focus should be on vitamin D for calcium absorption. Option B is incorrect as potassium is generally not restricted in osteoarthritis. Option D is also incorrect as sodium restriction is more relevant for conditions like hypertension or heart failure, not specifically for osteoarthritis.

4. A healthcare professional is preparing to administer an intramuscular (IM) injection to a client. Which of the following actions should the healthcare professional take?

• A. Use a 1-inch needle.
• B. Insert the needle at a 45-degree angle.
• C. Aspirate before injecting the medication.
• D. Administer the injection in the deltoid muscle.

Correct answer: C

Rationale: Aspirating before injecting the medication is a crucial step in IM injections to check for blood return, ensuring that the needle is not in a blood vessel. This technique helps prevent accidental intravascular injection of the medication, reducing the risk of complications such as inadvertent intravenous administration of the substance.

5. What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?

• A. Flush the feeding tube with water before and after feedings.
• B. Elevate the head of the bed to 30-45 degrees during feedings.
• C. Administer the feeding slowly.
• D. Check the client's weight daily.

Correct answer: B

Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.

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