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. In an extreme situation and when no other resident or intern is available, should a nurse receive telephone orders, the order has to be correctly written and signed by the physician within:

• A. 24 hours
• B. 36 hours
• C. 48 hours
• D. 12 hours

Correct answer: B

Rationale: In an extreme situation where no other resident or intern is available, if a nurse receives telephone orders, the order has to be correctly written and signed by the physician within 36 hours. This time frame ensures timely documentation and validation of the orders. Choice A (24 hours) is too short a period for busy physicians to fulfill the task. Choice C (48 hours) is too long and delays the incorporation of physician orders into the patient's care plan. Choice D (12 hours) may not provide enough time for the physician to review and sign the order, especially in situations where immediate attention is not required.

3. What laboratory value would be considered a high-risk measure for coronary heart disease assessment?

• A. triglycerides > 150 mg/dL
• B. BMI > 31
• C. LDL cholesterol < 128 mg/dL
• D. blood pressure of 128/82 mmHg

Correct answer: B

Rationale: The correct answer is B: BMI > 31. A BMI over 31 is considered a high-risk factor for coronary heart disease as it indicates obesity, which is strongly linked to cardiovascular issues. Triglycerides > 150 mg/dL (choice A) can contribute to heart disease risk but are not as specific as BMI in assessing overall risk. LDL cholesterol < 128 mg/dL (choice C) is actually a desirable level, indicating lower risk. A blood pressure of 128/82 mmHg (choice D) is within normal range and not a high-risk measure specifically for coronary heart disease.

4. A client needs to increase his protein intake and enjoys certain foods. Which of the following foods should the nurse recommend as the best source of protein among these suggestions?

• A. Yams
• B. Eggs
• C. Chicken
• D. Peanuts

Correct answer: C

Rationale: Chicken is the best source of protein among the options provided. It is a lean source of protein and contains essential amino acids needed for the body. Eggs are also a good source of protein, but chicken typically contains more protein per serving compared to eggs. Peanuts are a good source of plant-based protein, but chicken provides a higher amount of protein and is usually leaner. Yams, while nutritious, are not a significant source of protein compared to chicken, eggs, or peanuts.

5. Which factor contributes to the development of bone diseases in patients with Chronic Kidney Disease (CKD) due to retention?

• A. Iron
• B. Sodium
• C. Potassium
• D. Phosphorus

Correct answer: D

Rationale: The correct answer is phosphorus. Retention of phosphorus in patients with Chronic Kidney Disease (CKD) contributes to the development of bone disorders, including osteodystrophy, because it disrupts the balance of calcium and phosphorus in the body. This imbalance leads to a variety of bone diseases. The other options - iron, sodium, and potassium - while important in the overall metabolic function, are not directly linked to the development of bone diseases in CKD patients due to retention.

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