Nursing Elites

1. During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?

• A. Ask the patient how he or she is feeling.
• B. Document the findings in the patient's record.
• C. Wait 10 minutes and auscultate the sound again.
• D. Ask another nurse to double-check the finding.

Correct answer: D

Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.

2. What is the primary purpose of emergency planning?

• A. Comply with the laws of the state.
• B. Comply with the laws of the U.S.
• C. Comply with both state and U.S. laws
• D. Maintain safety

Correct answer: D

Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.

3. The nurse is reviewing concepts related to one's heritage and beliefs. Which concept refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe?

• A. Culture
• B. Religion
• C. Ethnicity
• D. Spirituality

Correct answer: B

Rationale: Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services. Religion is a shared experience of spirituality or the values, beliefs, and practices into which people are either born or that they may adopt to meet their personal spiritual needs through communal actions, such as religious affiliation, attendance and participation in a religious institution, prayer, or meditation, and religious practices. Culture is a complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It does not refer to a belief in a divine or superhuman power. Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, race, and others. Spirituality is a broad term focused on a connection with something bigger than oneself and a belief in transcendence.

4. When a patient is standing in anatomical position, where are their feet?

• A. Facing forward with the toes spread open
• B. Facing out to the sides to open the hips
• C. Side by side and facing forward; toes resting comfortably
• D. The feet are pointed inward.

Correct answer: B

Rationale: When a person is standing in anatomical position, their feet are side by side, and they are facing forward with the toes pointing out to the sides to open the hips. This position allows for proper alignment of the body for anatomical reference. Choice A is incorrect because the feet should not be spread open, but rather side by side. Choice C is incorrect as it does not mention the correct positioning of the feet. Choice D is incorrect as the feet should not be pointed inward, but rather facing out to the sides to open the hips.

5. When preparing to perform a physical examination on an infant, what should the nurse do?

• A. Have the parent remove all clothing except the diaper.
• B. Instruct the parent not to feed the infant immediately before the examination.
• C. Allow the infant to suck on a pacifier during abdominal auscultation.
• D. Ensure the parent is present during the examination.

Correct answer: A

Rationale: For performing a physical examination on an infant, it is important to have the parent remove all clothing except the diaper to allow for a thorough examination while ensuring the infant remains comfortable. It is recommended not to feed the infant immediately before the examination but rather 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. While a pacifier may be used during invasive assessments or if the infant is crying, it is not typically necessary during abdominal auscultation. Having the parent present during the examination is important for the infant's security and for the parent to understand the process; however, the clothing should still be removed except for the diaper to facilitate a comprehensive assessment.

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