Nursing Elites

1. When auscultating breath sounds, the nurse auscultates over the following locations:

• A. Trachea and lateral areas of thoracic cage
• B. Anterior and posterior aspects of all lung fields
• C. The mid section as well as the lateral section of the lungs
• D. The mid-clavicular to mid-axillary lines comparing side to side

Correct answer: B

Rationale: The correct answer is B: Anterior and posterior aspects of all lung fields. When auscultating breath sounds, it is essential to listen to the front (anterior) and back (posterior) aspects of all lung fields. This comprehensive approach allows for a thorough assessment of breath sounds throughout the lungs. Choices A, C, and D are incorrect. Choice A is too limited as it only focuses on the trachea and lateral areas, not covering all lung fields. Choice C is also too limited, referring to specific sections of the lungs (mid section and lateral section). Choice D is incorrect as it suggests comparing specific lines on the chest (mid-clavicular to mid-axillary), which is not a standard practice for auscultating breath sounds.

2. Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)

• A. Greater than 1000 cells per deciliter
• B. Less than 500 cells per deciliter
• C. Greater than 2000 cells per deciliter
• D. Less than 200 cells per deciliter

Correct answer: D

Rationale: A T4 cell count of less than 200 cells per deciliter indicates symptomatic AIDS. This severe depletion of T4 cells signifies advanced HIV infection and a significantly compromised immune system. Choices A, B, and C are incorrect because T4 cell counts above 2000, above 1000, or below 500 cells per deciliter, respectively, are not indicative of symptomatic AIDS.

3. A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?

• A. cold, burning, aching, and numbness
• B. burning, aching, cold, and numbness
• C. aching, cold, burning, and numbness
• D. cold, aching, burning, and numbness

Correct answer: A

Rationale: The correct order of sensations experienced with an ice water bath is cold, burning, aching, and numbness, as stated by the acronym CBAN (cold, burn, ache, numbness). Option A is the correct sequence. Choice B is incorrect as it starts with burning, which typically follows the cold sensation. Choice C is incorrect as aching is usually felt after the burning sensation. Choice D is incorrect as aching usually occurs after the burning sensation.

4. What is pica?

• A. dependency on alcohol
• B. increased iron in the diet
• C. the sickle cell trait
• D. eating ice

Correct answer: D

Rationale: Pica is a disorder characterized by the ingestion of nonfood substances, which can lead to a clinical iron deficiency. It may be the first sign of an underlying issue. Individuals with pica consume a variety of nonfood items such as ice, clay, dirt, or paste. Choice A, dependency on alcohol, is incorrect as it is not related to pica. Choice B, increased iron in the diet, is incorrect because pica involves ingesting nonfood items rather than having an increased intake of iron. Choice C, the sickle cell trait, is unrelated to pica and is therefore incorrect.

5. Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and provides the couple with which information?

• A. If the oral tablets are not successful, the medication will be administered intravenously.
• B. The couple should engage in coitus at least every other day during treatment.
• C. The physician should be notified immediately if breast engorgement occurs.
• D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies.

Correct answer: D

Rationale: The correct answer is that multiple births (usually twins) occur in a small percentage (8% - 10%) of clomiphene-facilitated pregnancies. The couple should be informed about this potential outcome. Clomiphene is available in 50-mg tablets for oral use; there is no intravenous form of the medication. Breast engorgement is a common side effect of clomiphene that typically resolves after discontinuation of the medication. Ovulation usually happens 5 to 10 days after the last dose of clomiphene, and the couple is advised to engage in coitus at least every other day during this time. Therefore, choices A, B, and C are incorrect as they do not provide accurate information regarding clomiphene treatment for infertility.

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