Nursing Elites

1. What are the correct steps used for abdominal assessment?

• A. Inspection, auscultation, percussion, palpation
• B. Palpation, inspection, auscultation, percussion
• C. Percussion, palpation, inspection, auscultation
• D. Auscultation, palpation, percussion, inspection

Correct answer: A

Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation follows to listen for bowel sounds and vascular sounds. Percussion helps to assess the density of underlying structures and detect any abnormal masses. Palpation is performed last to assess tenderness, organ size, and detect any masses. Choices B, C, and D have the steps in the incorrect order, making them the wrong choices.

2. When admitting a client with an abdominal wound, which precaution should be taken?

• A. Contact precautions
• B. Droplet precautions
• C. Airborne precautions
• D. Standard precautions

Correct answer: A

Rationale: When admitting a client with an abdominal wound, contact precautions should be implemented. Contact precautions are used to prevent the spread of infections that are spread by direct or indirect contact. In the case of abdominal wounds, bacteria and pathogens can easily be transmitted through contact with the wound or wound drainage. Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. Airborne precautions are used for infections spread through the air, like tuberculosis. Standard precautions are used for all clients to prevent the spread of infections and should be followed in addition to specific precautions based on the type of infection.

3. The client with gastroesophageal reflux disease (GERD) is receiving dietary modification education from the nurse. Which statement by the client indicates a need for further teaching?

• A. I will avoid eating large meals before bedtime.
• B. I will limit coffee consumption to the morning hours.
• C. I will elevate the head of my bed while sleeping.
• D. I will avoid spicy and acidic foods.

Correct answer: B

Rationale: The correct answer is B. Clients with GERD should avoid coffee as it can relax the lower esophageal sphincter and exacerbate symptoms. Limiting coffee consumption to the morning hours may not be sufficient, as coffee can still contribute to GERD symptoms throughout the day. Choices A, C, and D are all appropriate strategies for managing GERD symptoms. Avoiding large meals before bedtime, elevating the head of the bed while sleeping, and steering clear of spicy and acidic foods are all recommended practices to help alleviate GERD symptoms. Therefore, the client's statement in option B indicates a need for further teaching to completely address dietary modifications for managing GERD.

4. A client with chronic kidney disease is receiving epoetin alfa (Epogen). Which laboratory value should the nurse monitor to determine the effectiveness of this medication?

• A. Serum creatinine
• B. Hemoglobin
• C. Blood urea nitrogen (BUN)
• D. Platelet count

Correct answer: B

Rationale: The correct answer is B: Hemoglobin. Epoetin alfa (Epogen) is a medication commonly used in clients with chronic kidney disease to stimulate red blood cell production. Monitoring hemoglobin levels is crucial to assess the effectiveness of epoetin alfa therapy. Hemoglobin levels reflect the oxygen-carrying capacity of the blood and indicate if the medication is successfully treating anemia associated with chronic kidney disease. Option A, serum creatinine, is a marker of kidney function, not the primary indicator of epoetin alfa effectiveness. Option C, blood urea nitrogen (BUN), is a measure of kidney function and hydration status. Option D, platelet count, assesses clotting ability and is unrelated to monitoring the effectiveness of epoetin alfa in treating anemia in chronic kidney disease.

5. A client has had their diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

• A. smoothie
• B. sliced banana
• C. pancakes
• D. sunny side up (fried) eggs

Correct answer: D

Rationale: The correct answer is 'D: sunny side up (fried) eggs.' Fried eggs should be removed as they are not suitable for a mechanical soft diet due to their texture. The yolk of a fried egg is usually too hard and can be difficult for a client on a mechanical soft diet to chew and swallow. Poached or scrambled eggs are better alternatives for this diet as they are softer and easier to consume. Choices A, B, and C are all suitable for a mechanical soft diet as they are softer in texture and easier to chew and swallow.

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