Nursing Elites

1. When palpating the client's neck for lymphadenopathy, where should the nurse position himself?

• A. At the client's back
• B. At the client's right side
• C. At the client's left side
• D. In front of a sitting client

Correct answer: D

Rationale: When palpating the client's neck for lymphadenopathy, the nurse should position himself in front of a sitting client. This positioning allows for easier access to the neck area and better visualization of any swelling or abnormalities in the lymph nodes. Being in front of the client ensures proper alignment and comfort for both the nurse and the client during the assessment. Choices A, B, and C are incorrect because positioning at the client's back or sides would make it challenging to adequately palpate the neck area and assess for lymphadenopathy.

2. Short-bowel syndrome usually occurs when:

• A. The longitudinal muscles of the intestine contract
• B. More than 50% of the small intestine is surgically removed
• C. More than 50% of the large intestine is surgically removed
• D. Transit time is decreased due to infection or drugs

Correct answer: B

Rationale: Short-bowel syndrome usually occurs when more than 50% of the small intestine is surgically removed. This condition results in malabsorption of nutrients and fluids due to the reduced length of the small intestine. Choice A is incorrect because the contraction of longitudinal muscles does not lead to short-bowel syndrome. Choice C is incorrect as short-bowel syndrome is primarily related to the small intestine, not the large intestine. Choice D is incorrect since decreased transit time due to infection or drugs is not a direct cause of short-bowel syndrome.

3. When assessing a client for an endocrine dysfunction, which question should the nurse ask?

• A. “Have you noticed any pain in your legs when walking?”
• B. “Have you had any unexplained weight loss?”
• C. “Have you noticed any change in your bowel movements?”
• D. “Have you experienced any joint pain or discomfort?”

Correct answer: B

Rationale: The correct answer is B: “Have you had any unexplained weight loss?” Unexplained weight loss can be a common symptom of various endocrine disorders, such as hyperthyroidism and diabetes. This weight loss is often despite an adequate or increased appetite. Choices A, C, and D are less likely to be directly associated with endocrine dysfunction. Pain in the legs when walking could be related to musculoskeletal issues, changes in bowel movements may suggest gastrointestinal concerns, and joint pain is more commonly linked to rheumatologic conditions rather than primary endocrine disorders.

4. The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?

• A. Hold the medication
• B. Administer the digoxin
• C. Notify the healthcare provider
• D. Recheck the apical rate in 1 hour

Correct answer: B

Rationale: An apical rate of 140 bpm is within the normal range for a newborn. Digoxin is commonly used to treat heart failure by increasing the strength and efficiency of the heart's contractions. Since the heart rate is within the normal range, there is no need to hold the medication or notify the healthcare provider. Rechecking the apical rate in an hour is unnecessary as the heart rate is not alarming. Therefore, the appropriate nursing action is to administer the digoxin.

5. Which of the following nursing interventions is important for a client scheduled to have a Guaiac Test?

• A. Avoid turnips, radish, and horseradish 3 days before
• B. Continue iron preparation to prevent further loss of iron
• C. Do not consume red meat 12 hours before the procedure
• D. Encourage consumption of dark-colored foods with caffeine

Correct answer: A

Rationale: The correct answer is A. Turnips, radish, and horseradish are known to cause false-positive results in a Guaiac Test, which is used to detect blood in the stool. Avoiding these foods is crucial to ensure accurate test results. Choice B is incorrect because iron preparations can interfere with the test results. Choice C is incorrect as red meat does not impact the Guaiac Test significantly. Choice D is incorrect as caffeine and dark-colored foods are not relevant to the preparation for a Guaiac Test.

Similar Questions