Nursing Elites

1. Nurse DMLM is correct in identifying the correct sequence of events during abdominal assessment if she identifies which of the following?

• A. Inspection, Auscultation, Percussion, Palpation
• B. Inspection, Percussion, Palpation, Auscultation
• C. Inspection, Palpation, Percussion, Auscultation
• D. Inspection, Auscultation, Palpation, Percussion

Correct answer: D

Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation, Percussion, Palpation. Start with Inspection to observe any visible abnormalities, followed by Auscultation to listen for bowel sounds, then Percussion to assess the density of underlying structures, and finally Palpation to feel for any tenderness or masses. Choices A, B, and C have the incorrect sequence of assessment techniques.

2. You are doing bed bath to the client when suddenly, The nursing assistant rushed to the room and tell you that the client from the other room was in Pain. The best intervention in such case is:

• A. Raise the side rails, cover the client and put the call bell within reach and then attend to the client in pain to give the
• B. Tell the nursing assistant to give the pain medication to the client complaining of pain
• C. Tell the nursing assistant to go the client’s room and tell the client to wait
• D. Finish the bed bath quickly then rush to the client in Pain

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

3. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

• A. Ensure that the bed linen is always dry
• B. Frequently check the bed for wetness and keep it dry
• C. Place a rubber sheet under the client's buttocks
• D. Keep the patient clean and dry

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

4. The rationales for using a prostaglandin gel for a client prior to the induction of labor is to:

• A. Soften and efface the cervix
• B. Numb cervical pain receptors
• C. Prevent cervical lacerations
• D. Stimulate uterine contractions

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

5. Clients may benefit from slightly higher fat intakes than are normally recommended if they have:

• A. congestive heart failure
• B. cerebrovascular accident
• C. peripheral vascular disease
• D. chronic obstructive pulmonary disease

Correct answer: D

Rationale: In chronic obstructive pulmonary disease (COPD), higher fat intake can be beneficial because it provides more calories with less respiratory burden compared to carbohydrates. Choices A, B, and C are incorrect because congestive heart failure, cerebrovascular accident, and peripheral vascular disease do not specifically benefit from higher fat intakes as in COPD.

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