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. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:

• A. Amount of food and fluid taken during the last meal before treatment
• B. Respiratory rate, breath sounds, and location of congestion
• C. Teaching the client's relatives to perform the procedure
• D. Doctor's order regarding position restrictions and client's tolerance for lying flat

Correct answer: B

Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.

3. Approximately 70 to 80 percent of acute pancreatitis cases are caused by gallstones or _____.

• A. infection
• B. alcohol abuse
• C. diabetes
• D. obesity

Correct answer: B

Rationale: Alcohol abuse is indeed a major cause of acute pancreatitis, along with gallstones, accounting for the majority of cases. While infections, diabetes, and obesity can also contribute to pancreatitis, they are not as prevalent as alcohol abuse and gallstones in causing acute pancreatitis.

4. A nurse is planning care for a client who reports increasing difficulty swallowing food. Which of the following interventions should the nurse plan to take?

• A. Turn on the client’s television during meals.
• B. Place the client into a semi-reclining position for meals.
• C. Encourage the client to rest prior to mealtimes.
• D. Encourage the client to use a straw when drinking liquids.

Correct answer: C

Rationale: The correct answer is to encourage the client to rest prior to mealtimes. This intervention can help reduce fatigue and improve the ability to swallow. Turning on the client’s television during meals (choice A) may distract the client but does not directly address the swallowing issue. Placing the client into a semi-reclining position for meals (choice B) can help with swallowing difficulties, but resting before meals is more beneficial. Encouraging the client to use a straw when drinking liquids (choice D) is not the priority intervention for swallowing difficulties in this scenario.

5. The ideal time to begin taking folate to prevent neural tube defects is:

• A. Before conception
• B. Once pregnancy begins
• C. At 6 weeks
• D. Upon completion of the first trimester

Correct answer: A

Rationale: Folate is crucial before conception to prevent neural tube defects. Neural tube development occurs early in pregnancy, often before a woman knows she is pregnant.

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