Nursing Elites

1. The instructor is teaching a class on basic assessment skills. Which of the following statements is true regarding the stethoscope and its use?

• A. Slope of the earpieces should point forward toward the examiner's nose.
• B. It blocks out extraneous room noise but does not magnify sound.
• C. The tubing length should be 14 to 18 inches to prevent sound distortion.
• D. Both fit and quality of the stethoscope are important.

Correct answer: B

Rationale: The stethoscope does not magnify sound but effectively blocks out extraneous room noises. The correct orientation of the earpieces is with the slope pointing forward toward the examiner's nose, not posteriorly. The tubing length of a stethoscope should ideally be between 14 to 18 inches (36 to 46 cm) to avoid sound distortion. Using tubing longer than this range can distort sound. Both the fit and quality of the stethoscope are crucial for accurate auscultation and assessment, highlighting their significance in clinical practice. Therefore, the correct answer is that the stethoscope blocks out extraneous room noise but does not magnify sound.

2. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

• A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
• B. Obtain a thorough history and physical assessment from the patient's family member.
• C. Immediately perform a complete history and physical assessment to obtain baseline information.
• D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.

Correct answer: D

Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.

3. When providing mouth care to a patient in a coma, what should you do to provide good and safe mouth care?

• A. keep the head of the bed up to prevent aspiration
• B. brush the teeth and rinse the mouth with a cup of water
• C. use a special foam swab to brush only the tongue
• D. use a special foam swab to brush the tongue and teeth

Correct answer: D

Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice C) or using a foam swab only on the tongue (choice B) may not provide the comprehensive mouth care necessary for patients in a coma.

4. Each small square on the EKG paper is:

• A. 0.04 seconds long and 5mm tall
• B. 0.2 seconds long and 5mm tall
• C. 0.04 seconds long and 20mm tall
• D. 0.04 seconds long and 1mm tall

Correct answer: D

Rationale: Each small square on an EKG paper represents 0.04 seconds long and 1mm tall. This standardization is essential for accurate measurements. One large square on EKG paper consists of 5 small squares in length and 5 small squares in height, which equals 0.2 seconds long and 5mm tall (0.5 mV). Choice A is incorrect because while the duration is correct, the height mentioned is not accurate. Choice B is incorrect as it provides the correct height but the duration is inaccurate. Choice C is incorrect as the height mentioned is exaggerated, and the duration is correct but the height is not. Therefore, the correct answer is 0.04 seconds long and 1mm tall.

5. During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?

• A. Constipation
• B. Air-filled areas
• C. Presence of a tumor
• D. Presence of dense organs

Correct answer: B

Rationale: A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.

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