Nursing Elites

1. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Palpate the abdomen before auscultation
• B. Inspect the abdomen after palpation
• C. Auscultate before palpation
• D. Start by percussing the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation when performing an abdominal assessment. This sequence is crucial to prevent altering bowel sounds. Starting with palpation (Choice A) can lead to false interpretations of bowel sounds due to stimulation of the intestines. Inspecting the abdomen after palpation (Choice B) can also potentially alter the assessment findings. Starting with percussion (Choice D) is not recommended as it should come after auscultation to further assess underlying structures.

2. A nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration. What finding should the nurse intervene for?

• A. Heart rate of 80 beats per minute
• B. Heart rate of 120 beats per minute
• C. Blood pressure of 110/70 mmHg
• D. Respiratory rate of 16 breaths per minute

Correct answer: B

Rationale: A heart rate of 120 beats per minute indicates tachycardia, which can be a sign of dehydration and requires intervention. A heart rate of 80 beats per minute is within the normal range and does not indicate dehydration. A blood pressure of 110/70 mmHg is considered normal. A respiratory rate of 16 breaths per minute is also within the normal range and does not point towards dehydration.

3. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What lifestyle modification should the nurse emphasize?

• A. Decrease potassium intake
• B. Increase fluid intake to 2 liters per day
• C. Avoid foods high in calcium
• D. Increase sodium intake

Correct answer: B

Rationale: The correct lifestyle modification that the nurse should emphasize for a client with hypertension is to increase fluid intake to 2 liters per day. Proper hydration helps manage hypertension by supporting kidney function in regulating blood pressure and by diluting sodium levels in the body. Decreasing potassium intake (Choice A) is not recommended, as potassium-rich foods like fruits and vegetables are beneficial for blood pressure control. Avoiding foods high in calcium (Choice C) is not directly related to managing hypertension, and increasing sodium intake (Choice D) is contraindicated as excess sodium can elevate blood pressure.

4. A nurse is preparing to administer enteral feedings to a client with an NG tube. Which action should the nurse take first?

• A. Flush the tube with 100 mL of water
• B. Verify tube placement
• C. Elevate the head of the bed
• D. Measure the residual gastric volume

Correct answer: B

Rationale: Verifying tube placement is the priority action the nurse should take before administering enteral feedings. This step ensures that the NG tube is correctly positioned, reducing the risk of complications such as aspiration pneumonia. Flushing the tube with water, elevating the head of the bed, and measuring residual gastric volume are important steps in enteral feeding administration but come after verifying tube placement. Flushing the tube with water helps clear the tubing, elevating the head of the bed reduces the risk of aspiration, and measuring residual gastric volume helps assess the client's tolerance to feedings.

5. A nurse is preparing to perform a routine abdominal assessment. Which action should the nurse take first?

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

Correct answer: B

Rationale: The correct answer is to auscultate bowel sounds. Auscultation should be performed before palpation during an abdominal assessment to avoid altering bowel sounds. Inspecting the abdomen is important but should follow auscultation. Percussion and palpation should be done after auscultation and inspection to ensure an accurate assessment.

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