Nursing Elites

1. A healthcare professional is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the healthcare professional use first?

• A. Inspection
• B. Palpation
• C. Auscultation
• D. Percussion

Correct answer: A

Rationale: Inspection is the initial step in abdominal assessment as it allows the healthcare professional to visually observe any abnormalities or signs of bloating. Palpation, auscultation, and percussion are subsequent assessment techniques that follow inspection. Palpation involves feeling for tenderness, masses, or organ enlargement; auscultation is listening for bowel sounds; and percussion is used to assess the density of underlying tissues or detect the presence of fluid or air in the abdomen. In the context of a client reporting bloating, the first step should be visual inspection to gather initial information. Palpation, auscultation, and percussion come after inspection to provide a more comprehensive assessment.

2. The healthcare professional caring for a patient who is immobile frequently checks for impaired skin integrity. What is the rationale for this action?

• A. Inadequate blood flow leads to decreased tissue ischemia.
• B. Patients with limited caloric intake develop thicker skin.
• C. Pressure reduces circulation to affected tissue.
• D. Verbalization of skin care needs is decreased.

Correct answer: C

Rationale: The rationale behind checking for impaired skin integrity in an immobile patient is that pressure reduces circulation to the affected tissue. Prolonged pressure on specific body parts can lead to reduced blood flow to those areas, causing tissue damage and potentially leading to pressure ulcers. Choices A, B, and D are incorrect because inadequate blood flow causing decreased tissue ischemia, limited caloric intake leading to thicker skin, and decreased verbalization of skin care needs are not directly related to the rationale for checking for impaired skin integrity in immobile patients.

3. The client has been diagnosed with deep vein thrombosis (DVT). Which symptom would be most concerning?

• A. Pain in the affected leg
• B. Redness and warmth in the affected leg
• C. Shortness of breath
• D. Swelling in the affected leg

Correct answer: C

Rationale: Shortness of breath is the most concerning symptom in a client with deep vein thrombosis (DVT) because it could indicate a pulmonary embolism, a life-threatening complication where a blood clot travels to the lungs. This condition requires immediate medical attention. While pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT, shortness of breath suggests a more critical situation that necessitates urgent intervention.

4. When admitting a 5-month-old who has vomited 9 times in the past 6 hours, what should the healthcare provider observe for signs of which overall imbalance?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Increased serum hemoglobin levels
• D. Decreased serum potassium levels

Correct answer: B

Rationale: When a 5-month-old infant vomits multiple times, there is a risk of developing metabolic alkalosis due to the loss of stomach acid. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. It is caused by the loss of hydrogen ions from the body, often through vomiting. Metabolic acidosis (choice A) is unlikely in this scenario because it is more commonly associated with conditions like renal failure or diabetic ketoacidosis. Choice C, increased serum hemoglobin levels, is not typically a direct consequence of vomiting. Choice D, decreased serum potassium levels, may occur with vomiting but is not the primary concern when a patient is vomiting excessively.

5. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the LPN/LVN implement?

• A. Provide additional coffee on the client's breakfast tray.
• B. Exchange the client's grape juice for cranberry juice.
• C. Bring the client additional fruit at mid-morning.
• D. Encourage additional oral intake of juices and water.

Correct answer: D

Rationale: Encouraging additional oral intake of juices and water is the appropriate intervention in this scenario. Dark amber urine can indicate concentrated urine due to dehydration or other factors. By encouraging more fluids, the LPN/LVN can help dilute the urine, reducing the concentration of pigments causing the dark color. Providing additional coffee (Choice A) would not necessarily increase hydration and could potentially have a diuretic effect. Exchanging grape juice for cranberry juice (Choice B) does not address the core issue of hydration. Bringing additional fruit (Choice C) may provide some fluid, but encouraging specific fluids like juices and water would be more effective in diluting the urine.

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