Nursing Elites

1. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

• A. Notify the healthcare provider
• B. Document that the pericarditis has resolved
• C. Ask the client to lean forward and listen again
• D. Prepare to insert a unilateral chest tube

Correct answer: C

Rationale: The correct action for the nurse to take when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. This position brings the heart closer to the chest wall, making it easier to detect a friction rub if present. Notifying the healthcare provider is not necessary at this point as it may just be a matter of positioning for better auscultation. Documenting that the pericarditis has resolved is premature without proper assessment. Preparing to insert a unilateral chest tube is not indicated based on the absence of a friction rub.

2. What is a primary intervention for managing hyperphosphatemia?

• A. Increasing calcium intake
• B. Increasing phosphorus intake
• C. Decreasing calcium intake
• D. Administering phosphate binders

Correct answer: D

Rationale: Administering phosphate binders is a primary intervention for managing hyperphosphatemia. Phosphate binders work by binding phosphorus in the gut, preventing its absorption. Increasing calcium intake (Choice A) is not a primary intervention for hyperphosphatemia and can actually exacerbate the condition by potentially raising calcium levels. Increasing phosphorus intake (Choice B) is contraindicated in hyperphosphatemia. Decreasing calcium intake (Choice C) may help manage hypercalcemia but is not the primary intervention for hyperphosphatemia.

3. The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following? (Select all that apply)

• A. Obtain the pulses in all four extremities
• B. Ask the client to grasp and squeeze two fingers on each of the nurse’s hands
• C. Determine the client’s orientation to person, place, and time
• D. B, C

Correct answer: D

Rationale: The correct choices are B and C. Assessing grasp strength and orientation to person, place, and time are essential components of a neurological assessment after a CVA. Pulse assessment in all four extremities is more relevant to circulatory assessment rather than neurological status. Therefore, option A is incorrect.

4. Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task 'Know what your soldiers are doing during duty hours'?

• A. Accountability
• B. Personal/professional development
• C. Individual training
• D. Military appearance/physical condition

Correct answer: A

Rationale: The correct answer is A: Accountability. Accountability involves knowing what individuals are doing during duty hours, ensuring they are responsible and answerable for their actions. Personal/professional development (choice B) refers to enhancing one's skills and knowledge, individual training (choice C) focuses on specific training needs, and military appearance/physical condition (choice D) pertains to the physical presentation and fitness of individuals, not directly related to knowing what they are doing during duty hours.

5. The best position for any procedure that involves vaginal and cervical examination is

• A. Dorsal recumbent
• B. Side lying
• C. Supine
• D. Lithotomy

Correct answer: D

Rationale: The lithotomy position is the most suitable position for procedures involving vaginal and cervical examination because it provides the best access to the vaginal and cervical regions. In this position, the patient lies on their back with their legs flexed and feet placed in stirrups, allowing for optimal visualization and access to the area. This position facilitates proper examination, diagnosis, and treatment when working in the gynecological field. The other options (dorsal recumbent, side lying, and supine) do not provide the same level of access and visualization as the lithotomy position, making them less ideal for vaginal and cervical examinations.

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