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 a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skill should the nurse expect?

• A. Jumps with both feet
• B. Runs with coordination
• C. Walks without assistance
• D. Kicks a ball forward

Correct answer: C

Rationale: At 15 months, a toddler should be able to walk without assistance. Walking without assistance is a major gross motor skill milestone at this age, indicating the child's physical development and coordination. Choices A, B, and D are developmentally inappropriate for a 15-month-old. Jumping with both feet, running with coordination, and kicking a ball forward typically develop later in a child's growth and are more advanced skills compared to walking independently.

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

• A. I will soak my feet in hot water every day
• B. I will wear cotton socks at all times
• C. I will cut my toenails in a rounded shape
• D. I will apply lotion between my toes after bathing

Correct answer: B

Rationale: The correct answer is B. Wearing cotton socks is essential for clients with diabetes as it helps protect the feet and reduces the risk of skin breakdown. Choice A is incorrect because soaking feet in hot water can lead to burns or skin damage. Choice C is incorrect as clients with diabetes should cut their toenails straight across to prevent ingrown toenails. Choice D is incorrect as applying lotion between the toes can create a moist environment that may increase the risk of fungal infections.

4. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?

• A. Encourage a high-protein diet
• B. Apply a moisture-retentive dressing
• C. Provide daily wound irrigation
• D. Apply an ice pack to the wound

Correct answer: B

Rationale: The correct answer is to apply a moisture-retentive dressing. This promotes a moist wound environment, which is crucial for wound healing in clients with diabetes. Encouraging a high-protein diet may support overall health but is not directly related to wound healing. Daily wound irrigation can disrupt the wound healing process by removing necessary growth factors and cells. Applying an ice pack to the wound is contraindicated as it can impair circulation and delay wound healing.

5. A nurse is preparing to administer enteral feedings to a client with a nasogastric (NG) tube. What action should the nurse take first?

• A. Measure the residual gastric volume
• B. Verify tube placement
• C. Flush the tube with 100 mL of water
• D. Administer the feeding in small boluses

Correct answer: B

Rationale: Verifying tube placement is the crucial initial step a nurse should take before administering enteral feedings through an NG tube. This step ensures that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Measuring residual gastric volume, flushing the tube with water, or administering the feeding in small boluses are all important steps in enteral feeding but should only be done after confirming the correct tube placement.

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