Nursing Elites

1. A nurse palpates a client’s radial pulse, noting the rate, rhythm, and force, and concludes that the client’s pulse is normal. Which notation would the nurse make in the client’s record to document the force of the client’s pulse?

• A. 4+
• B. 3+
• C. 2+
• D. 1+

Correct answer: C

Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+ for a bounding pulse, 3+ for an increased pulse, 2+ for a normal pulse, and 1+ for a weak pulse. In this case, the nurse would grade the client’s pulse as 2+ based on the description of a normal pulse. Therefore, the correct notation for the force of the client’s pulse is '2+' as it indicates a normal pulse. Choices A, B, and D are incorrect as they represent different levels of pulse force that do not align with the description given in the scenario.

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. The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?

• A. Inform the staff on the other floor of any unresolved issues with the client.
• B. Ask the charge nurse if overtime would be permitted to complete the client's transfer to the other floor.
• C. Ask the new nurse to take care of the transfer since the client's medical record has all of the information, and a report should not be needed.
• D. Complete the transfer paperwork before the client is transferred.

Correct answer: C

Rationale: The least appropriate action in this scenario is to ask the new nurse to take care of the transfer without providing a full handoff of care. It is crucial to ensure a safe handoff during the transfer to maintain continuity of care and patient safety. Informing the staff on the other floor of any unresolved issues with the client (Choice A) is important for the client's well-being as it helps in providing comprehensive care. Asking the charge nurse about overtime (Choice B) demonstrates consideration for completing the task effectively, but it should not take precedence over ensuring a proper handoff. Completing the transfer paperwork before the client is transferred (Choice D) is necessary to ensure all documentation is in order, but it should be done in conjunction with providing a thorough handoff of care to the new nurse.

4. When a couple experiencing infertility presents for a fertility workup, which of the following procedures should the nurse prepare the couple to have first?

• A. Hysterosalpingography
• B. Semen analysis
• C. Endometrial biopsy
• D. Transvaginal ultrasound

Correct answer: B

Rationale: Semen analysis is the most appropriate initial diagnostic test for a couple experiencing infertility. It is the least invasive of the listed tests, and since male factor infertility contributes to around 35% of cases, assessing semen parameters early is crucial. Hysterosalpingography is a radiographic test to evaluate tubal patency and uterine cavity abnormalities. Endometrial biopsy assesses endometrial receptivity post-ovulation. Transvaginal ultrasound is mainly used in infertility treatment to monitor follicle development, oocyte maturity, and luteal phase defects. Choices A, C, and D are more invasive, require specialized expertise, and are costlier. If semen analysis yields normal results, further tests may be warranted.

5. While assisting with data collection of an adult client, a nurse asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?

• A. Optic
• B. Abducens
• C. Olfactory
• D. Hypoglossal

Correct answer: C

Rationale: The correct answer is 'Olfactory.' The olfactory nerve is responsible for the sense of smell. Assessing this nerve involves testing the client's ability to identify various odors. Loss of smell, head trauma, abnormal mental status, and suspected intracranial lesions are conditions where testing the olfactory nerve is essential. The optic nerve is evaluated for visual acuity and visual fields. The abducens nerve is usually assessed alongside the oculomotor and trochlear nerves, focusing on pupil size, regularity, light reactions, accommodation, and extraocular movements. The hypoglossal nerve is examined by inspecting the tongue, not by assessing the sense of smell.

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