Nursing Elites

1. The nurse is caring for an elderly female client who tells the nurse, 'When I sneeze, I wet my pants.' After discussing the client's complaint with the charge nurse, the nurse plans to reinforce teaching about the importance of Kegel exercises. What muscles are involved in these exercises?

• A. Pectoral muscles
• B. Buttock muscles
• C. Abdominal muscles
• D. Pelvic floor muscles

Correct answer: D

Rationale: Kegel exercises involve the pelvic floor muscles. These muscles help strengthen the muscles controlling urination, potentially reducing symptoms of urinary incontinence. Pectoral muscles (Choice A), responsible for movement of the shoulders and arms, are not involved in Kegel exercises. Buttock muscles (Choice B) are primarily responsible for hip movement and stability, not related to Kegel exercises. Abdominal muscles (Choice C) support the core and trunk but are not the focus of Kegel exercises.

2. Which task could the nurse safely delegate to the UAP?

• A. Oral feeding of a two-year-old child after application of a hip spica cast
• B. Assessment of the placement and patency of an NG tube
• C. Participation in staff rounds to record notes regarding client goals
• D. Evaluation of a client's incisional pain following narcotic administration

Correct answer: A

Rationale: The correct answer is A because oral feeding of a stable child is a task that can be safely delegated to a UAP. This task does not require nursing assessment or clinical judgment. Choice B involves assessment, which requires the nurse's clinical judgment. Choice C involves recording client goals during staff rounds, which may require interpretation and understanding of the goals set. Choice D involves evaluating a client's pain following medication administration, which requires assessment and clinical judgment by a nurse.

3. Which of the following is the best method for confirming nasogastric tube placement?

• A. Auscultating over the stomach while injecting air
• B. Checking the pH of the aspirate
• C. Observing the patient’s response during feeding
• D. Measuring the external length of the tube

Correct answer: B

Rationale: Checking the pH of the aspirate is the most reliable method to confirm nasogastric tube placement as it provides direct evidence of the tube's location in the stomach. When the pH is acidic (pH < 5), it indicates that the tube is correctly placed in the stomach. Auscultating over the stomach while injecting air may not always be accurate, as the sound can be misleading due to various factors. Observing the patient’s response during feeding is not a definitive method for confirming tube placement, as it can be influenced by other factors. Measuring the external length of the tube does not ensure correct placement within the GI tract and can be affected by external factors like patient anatomy.

4. The nurse is assisting with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the nurse take?

• A. Omit the section of the assessment form
• B. Ask her if she would like an interpreter to help her understand the question
• C. Reword the question to make it more culturally sensitive
• D. Observe the client's response when asked a different question

Correct answer: D

Rationale: Observing the client's response to another question is the most appropriate action in this scenario. By doing so, the nurse can assess whether the client's discomfort is due to cultural sensitivity or a misunderstanding. This approach allows the nurse to proceed with sensitivity and respect, ensuring effective communication. Option A is incorrect because omitting the section of the assessment form may result in missing crucial information relevant to the client's condition. Option B jumps to assumptions about a language barrier without confirming it first. Option C focuses on rewording the question without addressing the underlying issue causing the client's discomfort, which may not necessarily be due to a lack of understanding.

5. Which type of isolation precaution is required for a patient with tuberculosis (TB)?

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

Correct answer: C

Rationale: The correct answer is C: Airborne precautions. Tuberculosis (TB) is transmitted via airborne particles, thus requiring airborne precautions to prevent the spread of infection. This includes using an N95 respirator to filter out small infectious particles. Droplet precautions (Choice A) are used for diseases that spread through large respiratory droplets. Contact precautions (Choice B) are for direct or indirect contact with the patient or their environment. Standard precautions (Choice D) are used for all patients to prevent the spread of infection through blood, bodily fluids, non-intact skin, and mucous membranes.

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