Nursing Elites

1. A nurse is preparing to perform an abdominal assessment on a client. Which action should the nurse take first?

• A. Percuss the abdomen
• B. Inspect the abdomen
• C. Auscultate before palpation
• D. Palpate the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation. This ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen is a valid step but not the first. Percussing and palpating should come after auscultation to prevent altering bowel sounds or causing discomfort to the client.

2. A healthcare professional is reviewing the laboratory values of a client who is experiencing fluid volume deficit (FVD). What finding should the professional expect?

• A. Decreased hematocrit
• B. Increased hematocrit
• C. Decreased white blood cell count
• D. Increased red blood cell count

Correct answer: B

Rationale: The correct answer is 'Increased hematocrit.' In fluid volume deficit (FVD), there is a decrease in the amount of fluid in the blood vessels, leading to hemoconcentration. This results in an increase in hematocrit levels. Choices A, C, and D are incorrect because a decrease in hematocrit, decrease in white blood cell count, and an increase in red blood cell count are not typically seen in fluid volume deficit.

3. A nurse is caring for a client who reports pain and burning around the peripheral IV site. What is the nurse's priority action?

• A. Apply a warm compress
• B. Discontinue the IV line
• C. Increase the IV flow rate
• D. Elevate the limb

Correct answer: B

Rationale: The correct answer is B: Discontinue the IV line. When a client reports pain and burning around the peripheral IV site, it indicates possible phlebitis, which is inflammation of the vein. The priority action is to discontinue the IV line to prevent further complications such as infection or thrombosis. Applying a warm compress (Choice A) may worsen the inflammation. Increasing the IV flow rate (Choice C) can exacerbate the symptoms and elevate the risk of complications. Elevating the limb (Choice D) may provide comfort, but it does not address the underlying issue of phlebitis. Therefore, the priority action is to discontinue the IV line.

4. A nurse is caring for a client who has dementia and frequently tries to get out of bed. What actions should the nurse take? (Select all that apply)

• A. Turn off the bed alarm
• B. Use physical restraints
• C. Maintain the bed in the lowest position
• D. Apply a vest restraint

Correct answer: C

Rationale: Maintaining the bed in the lowest position is an appropriate action when caring for a client with dementia who tries to get out of bed. This helps reduce the risk of falls and ensures the client's safety. Turning off the bed alarm (Choice A) is not advisable as it can be a safety measure to alert the staff when the client tries to get out of bed. Using physical restraints (Choice B) and applying a vest restraint (Choice D) should be avoided as they can lead to physical and psychological harm, reduce mobility, and compromise the client's dignity.

5. A client who is postoperative following abdominal surgery is at risk for constipation due to which behavior?

• A. Increased fiber intake
• B. Decreased fluid intake
• C. Frequent urge suppression
• D. Increased physical activity

Correct answer: B

Rationale: Postoperative clients are at risk for constipation due to various factors, including decreased fluid intake. Insufficient fluid consumption can lead to hardening of stools, making them difficult to pass. Increased fiber intake (choice A) is actually beneficial for preventing constipation as it adds bulk to the stool. Frequent urge suppression (choice C) can contribute to constipation by disrupting normal bowel habits. Increased physical activity (choice D) generally helps promote bowel movements and reduce the risk of constipation.

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