Nursing Elites

1. A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?

• A. Normally heard in the lungs
• B. Hollow sounds heard over the trachea and larynx
• C. Rustling sounds heard over the peripheral lung fields
• D. Abnormal sounds that should not be heard in the lungs

Correct answer: D

Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious. Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.

2. Mr. H. is upset about being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:

• A. the right to examine and question the bill
• B. the right to reasonable response to requests
• C. the right to refuse treatment
• D. the right to confidentiality

Correct answer: D

Rationale: Confidentiality is the maintenance of privacy of information, which is not directly related to the issue Mr. H. is facing. The question indicates that Mr. H. is concerned about the cost of staying in the hospital, which pertains more to financial aspects and the right to examine and question the bill. The right to a reasonable response to requests and the right to refuse treatment are also crucial patient rights that Mr. H. may demand in his current situation. Therefore, the correct answer is the right to confidentiality, as it is not specifically relevant to the scenario presented.

3. 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 that decreases the immune response and increases the risk of disease. Therefore, all the options mentioned are important for cancer prevention, making 'All of the above' the correct response.

4. The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:

• A. administer both medications simultaneously
• B. give the medications sequentially, and flush well between them
• C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug
• D. start one medication now and begin the other medication in 2-4 hours

Correct answer: B

Rationale: The correct answer is to give the medications sequentially and flush well between them. Ampicillin has a pH of 8-10, while gentamicin has a pH of 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent any potential interactions. Option A is incorrect because administering both medications simultaneously can lead to incompatibility issues. Option C is incorrect because the nurse should already be aware of the correct administration sequence and not need to consult the physician or pharmacy each time. Option D is incorrect because delaying the second medication by several hours can slow down the treatment of the client's infection, which is not ideal in this scenario.

5. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?

• A. "I should put alcohol on my baby's cord 3-4 times a day."?
• B. "I should put the baby's diaper on so that it covers the cord."?
• C. "I should call the physician if the cord becomes dark."?
• D. "I should wash my hands before and after I take care of the cord."?

Correct answer: A

Rationale: Explanation: Parents should be taught that putting alcohol or other antimicrobials on the cord is no longer recommended for cord care. This can interfere with the natural healing process and may increase the risk of irritation or infection. Washing hands before and after providing cord care is essential to prevent the transfer of pathogens. Placing the baby's diaper below the cord allows it to be exposed to air and promotes drying, reducing the risk of infection. It is normal for the cord to turn dark as it dries, so calling the physician only if the cord becomes red, swollen, or has discharge is appropriate. Therefore, the statement '"I should put alcohol on my baby's cord 3-4 times a day."?' indicates a need for further teaching about cord care.

Similar Questions