Nursing Elites

1. A nurse is telling a pregnant client about the signs that must be reported to the health care provider. The nurse tells the client that the health care provider should be contacted if which occurs?

• A. Puffiness of the face
• B. Breast tenderness
• C. Morning sickness
• D. Urinary frequency

Correct answer: A

Rationale: During pregnancy, it is important to be aware of danger signs that warrant contacting the healthcare provider. Puffiness of the face, especially around the eyes, can indicate a serious condition like preeclampsia. Other danger signs include vaginal bleeding, rupture of membranes, severe abdominal pain, visual disturbances, persistent vomiting, and changes in fetal movements. Morning sickness, breast tenderness, and urinary frequency are common symptoms of pregnancy and are not typically concerning unless they become severe or persistent, and do not usually require immediate medical attention.

2. A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?

• A. By checking the client's urine for blood
• B. By checking the client's stool for blood
• C. By checking the client's urine for a decrease in output
• D. By checking the client's bowel movements for diarrhea

Correct answer: B

Rationale: Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.

3. A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the nurse places the stethoscope over which area?

• A. Major bronchi
• B. The xiphoid process
• C. The trachea and larynx
• D. The peripheral lung fields

Correct answer: D

Rationale: To assess vesicular breath sounds, the nurse should place the stethoscope over the peripheral lung fields. Vesicular breath sounds are heard in these areas where air flows through the smaller bronchioles and alveoli. Bronchovesicular breath sounds, not vesicular, are heard over the major bronchi. Bronchial (tracheal) breath sounds are heard over the trachea and larynx, not vesicular sounds. Breath sounds are not heard over the xiphoid process, making it an incorrect choice.

4. A patient reports, "I tore 3 of my 4 Rotator cuff muscles in the past."? Which of the following muscles cannot be considered as possibly being torn?

• A. Teres minor
• B. Teres major
• C. Supraspinatus
• D. Infraspinatus

Correct answer: B

Rationale: The correct answer is Teres major. The Rotator Cuff consists of Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis muscles, not Teres major. Teres major is not part of the rotator cuff, so it cannot be considered as possibly being torn. The other choices, Teres minor, Supraspinatus, and Infraspinatus, are all part of the Rotator Cuff and could potentially be torn in this patient's case.

5. A client states, "I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?"? The nurse should respond with which of the following statements?

• A. Sleep at least 6-8 hours per night.
• B. Practice monthly self-breast examinations.
• C. Reduce stress.
• D. All of the above.

Correct answer: D

Rationale: All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. Stress can have a physiological response in the body that decreases the immune response and increases the risk of disease. Therefore, all the options provided are important in cancer prevention, making 'All of the above' the correct answer. Option A is crucial for overall health and immune function, option B aids in early detection, and option C is vital as chronic stress can weaken the immune system.

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