Nursing Elites

1. When a nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign, what does this indicate?

• A. That the cervix appears violet
• B. That cervical softening is present
• C. A positive sign of pregnancy
• D. A thinning of the cervix

Correct answer: A

Rationale: The correct interpretation of the Chadwick sign is that the cervix appears violet in color. This sign is a probable sign of pregnancy, characterized by the violet coloration of the cervix due to increased vascularity of the pelvic organs. It is not a definitive positive sign of pregnancy but rather a probable one. Choices B and D are incorrect as cervical softening is known as the Goodell sign, and thinning of the cervix is referred to as the Hegar sign. These signs are also probable signs of pregnancy, but they do not specifically indicate the Chadwick sign.

2. A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?

• A. Assessing visual acuity
• B. Inspecting the eyelids for ptosis
• C. Assessing pupil constriction
• D. Assessing ocular movements

Correct answer: A

Rationale: The correct technique to assess the optic nerve is by testing visual acuity and visual fields through confrontation. Visual acuity involves assessing the clarity of vision, which directly correlates with the function of the optic nerve. Inspecting the eyelids for ptosis is unrelated to optic nerve assessment. Assessing pupil constriction is more related to the assessment of cranial nerves controlling eye movements, particularly the oculomotor nerve. Assessing ocular movements is related to testing the abducens, oculomotor, and trochlear nerves, not specifically the optic nerve.

3. What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?

• A. Dextrose concentrations below 20% can be safely administered through a peripheral IV; dextrose concentrations above 20% should not be administered through a peripheral IV.
• B. Dextrose concentrations below 5% can be safely administered through a peripheral IV; dextrose concentrations above 5% should not be administered through a peripheral IV.
• C. Dextrose concentrations below 10% can be safely administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.
• D. Dextrose concentrations above 5% can be safely administered through a peripheral IV; dextrose concentrations below 5% should not be administered through a peripheral IV.

Correct answer: C

Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.

4. A nurse is reading the report from the registered nurse for an initial home visit to a client with chronic obstructive pulmonary disease. The client was recently discharged from the hospital. Which type of database does the nurse read that contains this information from the client?

• A. Episodic
• B. Follow-up
• C. Emergency
• D. Complete

Correct answer: D

Rationale: The correct answer is 'Complete.' A complete database includes a full health history and physical examination, providing a comprehensive overview of the client's current and past health status. This type of database establishes a baseline for future assessments, making it essential for the nurse's initial home visit to understand the client's health needs thoroughly post-hospital discharge. It is typically gathered in primary care settings like clinics, private practices, college health services, women's health care agencies, visiting nurse agencies, or community health agencies. An episodic database focuses on a specific short-term issue or body system, which is not comprehensive enough for the initial home visit after hospital discharge. A follow-up database is used to monitor a known problem at regular intervals, not suitable for an initial assessment. An emergency database is swiftly collected during urgent situations, often while lifesaving measures are being carried out, and is not relevant for a post-hospital discharge home visit.

5. A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?

• A. Left upper quadrant
• B. Left lower quadrant
• C. Right upper quadrant
• D. Right lower quadrant

Correct answer: D

Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there. Then, the nurse proceeds to listen for bowel sounds in the other quadrants. Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.

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