Nursing Elites

1. A client is scheduled to undergo a Papanicolaou (Pap) test in 1 week. Which statement does the nurse make to the client?

• A. 'If you are menstruating, use pads instead of a tampon.'
• B. 'Avoid intercourse for 24 hours before the scheduled examination.'
• C. 'Get a douching kit from the pharmacy and douche 2 hours before the examination.'
• D. 'If you are having a vaginal discharge, obtain a sample of the discharge for inspection.'

Correct answer: B

Rationale: The correct answer is to 'Avoid intercourse for 24 hours before the scheduled examination.' The Pap test is used to screen for cervical cancer. It is not performed during menstruation or if a heavy infectious discharge is present. Before the test, the client should not douche, have intercourse, or insert anything into the vagina within 24 hours. Instructing the client to use pads instead of a tampon when menstruating can interfere with the test results due to the presence of blood. Douching before the exam is discouraged as it can alter the cervical cells' appearance, affecting the test's accuracy. Obtaining a sample of vaginal discharge for inspection is not a standard pre-Pap test instruction and is unnecessary for the test.

2. A healthcare provider is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the healthcare provider first place an activated tuning fork?

• A. On the client's teeth
• B. On the client's forehead
• C. On the client's mastoid bone
• D. On the midline of the client's skull

Correct answer: C

Rationale: In the Rinne test, the base of an activated tuning fork is held first against the mastoid bone, behind the ear, and then in front of the ear canal (0.5 to 2 inches). When the client no longer perceives the sound behind the ear, the fork is moved in front of the ear canal until the client indicates that the sound can no longer be heard. The client reports whether the sound from the tuning fork is louder behind the ear (on the mastoid bone) or in front of the ear canal. Placing the tuning fork on the teeth (Choice A), forehead (Choice B), or the midline of the skull (Choice D) is not part of the Rinne test procedure. Therefore, the correct answer is to first place the activated tuning fork on the client's mastoid bone.

3. While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6�F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?

• A. Notify the registered nurse of the findings.
• B. Document the findings in the client's medical record.
• C. Recheck the vital signs in 1 hour.
• D. Continue collecting subjective and objective data.

Correct answer: A

Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98�F to 99.6�F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4�F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.

4. A nurse preparing to examine a client’s eyes plans to perform a confrontation test. The nurse tells the client that this test measures which aspect of vision?

• A. Near vision
• B. Color vision
• C. Distant vision
• D. Peripheral vision

Correct answer: D

Rationale: The correct answer is D: Peripheral vision. The confrontation test is a gross measure of peripheral vision. It compares the client’s peripheral vision with the nurse’s, assuming that the nurse’s vision is normal. During the test, the nurse positions themselves at eye level with the client, about 2 feet away, and directs the client to cover one eye with an opaque card. The nurse covers the eye opposite the client’s covered one and slowly moves a target (like a pencil) from the periphery in several directions. The client is asked to indicate when they see the target, which should coincide with when the nurse sees it. Near vision is tested using a handheld vision screener with various sizes of print, color vision with the Ishihara test, and distant vision with a Snellen chart. Therefore, choices A, B, and C are incorrect as they do not measure peripheral vision, which is the focus of the confrontation test.

5. A sexually active married couple, discussing birth control methods with the nurse, expresses the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest?

• A. Diaphragm
• B. Sterilization
• C. Male condom
• D. Spermicide

Correct answer: B

Rationale: In this scenario, since the couple has indicated that their family-planning goals have been met, a permanent method of contraception like sterilization would be most suitable. Sterilization offers long-term effectiveness and convenience once the decision to stop having children is made. Options like the diaphragm, male condom, or spermicide are more suitable for temporary contraception or when the family-planning goals have not yet been achieved. Therefore, the correct answer is sterilization, as it aligns with the couple's need for a convenient and permanent birth control method.

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