Nursing Elites

1. When counting an infant's respirations, which technique is correct?

• A. Watching the chest rise and fall
• B. Observing the movement of the abdomen
• C. Placing a hand across the infant's chest
• D. Using a stethoscope to listen to the breath sounds

Correct answer: B

Rationale: The correct technique for counting an infant's respirations is to observe the movement of the abdomen. Infants typically have more diaphragmatic breathing than thoracic, so watching the abdomen provides a more accurate count. Placing a hand on the chest or listening with a stethoscope can alter the infant's breathing pattern and provide inaccurate results. Therefore, options A, C, and D are incorrect methods for counting an infant's respirations. By observing the movement of the abdomen, healthcare providers can accurately assess an infant's respiratory rate without influencing their breathing pattern.

2. Which of the following is an organizational factor that affects workplace violence directed at nurses?

• A. Clients who have short hospital stays
• B. The presence of security guards
• C. Restricted client areas
• D. Understaffing of nursing personnel

Correct answer: D

Rationale: Understaffing of nursing personnel is a critical organizational factor that can contribute to workplace violence directed at nurses. When there are too few nurses on duty due to understaffing, it can lead to delays in care delivery and inadequate attention to clients' needs. This situation can result in heightened frustration, aggression, or violence from clients or their families towards the nursing staff. On the other hand, the presence of security guards (Choice B) may enhance safety in the workplace and deter violence, making it an incorrect choice. Clients who have short hospital stays (Choice A) and restricted client areas (Choice C) are not directly linked to organizational factors that promote workplace violence against nurses, making them incorrect choices.

3. When is a physician likely to assess turgor?

• A. When iron deficiency is suspected.
• B. When heart and lung issues are suspected.
• C. When dehydration is suspected.
• D. None of the above.

Correct answer: C

Rationale: Skin turgor is assessed when dehydration is suspected. To evaluate skin turgor, a physician pinches the skin and observes how quickly it returns to its normal position. If the skin stays folded for an extended period, it indicates dehydration. Assessing turgor helps determine a patient's hydration status. Choice A is incorrect because skin turgor is not used to assess iron deficiency. Choice B is incorrect as turgor is not related to heart and lung issues, but rather hydration status. Choice D is incorrect as turgor assessment is relevant when dehydration is suspected.

4. A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?

• A. Assist the client to lie in the semi-Fowler position
• B. Apply lubricating jelly to the tip of the catheter before insertion
• C. Instill a total of 30cc of fluid into the client's rectum
• D. Ask the client to hold the solution in for 30 seconds

Correct answer: B

Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.

5. A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent?

• A. Relex incontinence
• B. Urge incontinence
• C. Total incontinence
• D. Functional incontinence

Correct answer: D

Rationale: Functional incontinence occurs when a client develops an urge to void but may not be able to reach the toilet in time. In this scenario, the client had the urge to use the restroom but was unable to make it in time, leading to incontinence. Functional incontinence may be related to conditions that cause the client to forget bladder sensation until the last minute, such as cognitive changes, or the client may have mobility problems that prevent her from reaching the bathroom in time. Choice A, Reflex incontinence, is incorrect as reflex incontinence is characterized by the involuntary loss of urine due to hyperreflexia of the detrusor muscle. Choice B, Urge incontinence, is not the correct answer as urge incontinence is the involuntary loss of urine associated with a strong desire to void. Choice C, Total incontinence, is also incorrect as it refers to the continuous and unpredictable loss of urine, not specifically related to the inability to reach the toilet in time.

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