Nursing Elites

1. When performing a physical assessment, what technique should the nurse always perform first?

• A. Palpation
• B. Inspection
• C. Percussion
• D. Auscultation

Correct answer: B

Rationale: During a physical assessment, the nurse should always begin with inspection. The sequence of techniques for physical examination is inspection, palpation, percussion, and auscultation. These skills are performed in a specific order, except for the abdominal assessment where auscultation precedes palpation and percussion. Inspection allows the nurse to observe and gather initial information without direct contact. It is a crucial step that provides valuable insights before proceeding to palpation, percussion, and auscultation. Therefore, choice B, 'Inspection,' is the correct answer. Choices A, C, and D are incorrect because they should follow inspection in the sequence of a comprehensive physical assessment.

2. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?

• A. The client's IV is infiltrated
• B. The client is experiencing phlebitis from the last drug administered
• C. The client has a blood clot developing in the distal arteries of the wrist
• D. The client's pain is associated with myocardial ischemia and he is having a heart attack

Correct answer: A

Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.

3. For a patient who is blood type AB, which blood product can they receive?

• A. Plasma from a type B donor
• B. Whole blood from a type A donor
• C. Packed RBCs from a type O donor
• D. All of the above

Correct answer: C

Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens. Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma. Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens. Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type. Therefore, choices A and B are incorrect, and the correct choice is C.

4. During a client interview, which of the following leading questions should the nurse avoid asking?

• A. What medication do you take at home?
• B. You are really excited about the plastic surgery, aren't you?
• C. Were you aware I've had this same type of surgery?
• D. What would you like to talk about?

Correct answer: B

Rationale: The nurse should avoid asking leading questions during a client interview as they can influence the client's response. Option B is a leading question as it suggests an expected response from the client, potentially biasing the information provided. This can lead to inaccurate data collection and subsequent errors in diagnostic reasoning. Choices A, C, and D are open-ended questions that encourage the client to provide unbiased information and allow for a more comprehensive assessment.

5. A patient's blood pressure is 118/82 mm Hg. The patient asks the nurse, "What do the numbers mean?"? Which is the best reply by the nurse?

• A. "The numbers are within the normal range and are nothing to worry about."?
• B. "The bottom number is the diastolic pressure and reflects the pressure in the arteries when the heart relaxes."?
• C. "The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts."?
• D. "The concept of blood pressure can be complex. The primary thing to be concerned about is the top number, or the systolic blood pressure."?

Correct answer: C

Rationale: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume. Both the systolic and diastolic blood pressure are important. Choice A is incorrect as providing a vague reassurance does not address the patient's query. Choice B is incorrect as it inaccurately describes the diastolic pressure as reflecting stroke volume, which is incorrect. Choice D is incorrect as it oversimplifies the explanation, focusing solely on the top number without providing a complete understanding of blood pressure.

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