Nursing Elites

1. When performing an abdominal assessment, what is the correct order of the tasks?

• A. inspect, percuss, palpate, auscultate
• B. inspect, palpate, percuss, auscultate
• C. inspect, auscultate, percuss, palpate
• D. inspect, palpate, auscultate, percuss

Correct answer: C

Rationale: The correct order of tasks when performing an abdominal assessment is to first inspect the abdomen visually, then auscultate to assess bowel sounds without altering them, followed by percussing to assess the presence of tympany or dullness, and finally palpating to feel for any tenderness, masses, or organ enlargement. Placing palpation or percussion before auscultation, as in choices A, B, and D, can affect the bowel sounds and examination findings, making them incorrect sequences.

2. The patient is inquiring about the use of a PCA pump for pain management. Which statement by the patient indicates a need for additional education?

• A. "I will continue to report my pain score during assessments."?
• B. "I understand that there is a maximum dose per hour that I can receive regardless of how many times I press the button."?
• C. "I believe this new PCA pump will finally alleviate my back pain."?
• D. "I have more control over when and how much medication I receive."?

Correct answer: C

Rationale: The correct answer is, "I believe this new PCA pump will finally alleviate my back pain."? This statement indicates a need for additional education as it reflects an unrealistic expectation regarding pain management. It is essential for the patient to understand that while a PCA pump can provide effective pain relief, it may not completely eliminate pain. Option A is correct as it demonstrates the patient's understanding of the importance of reporting pain scores for proper pain management. Option B is correct as it shows the patient's awareness of the maximum dose limits to prevent overdose. Option D is correct as it highlights the patient's understanding of the control they have over their medication administration.

3. Which of the following would likely not impede learning?

• A. a client who took Ambien� an hour ago
• B. a bipolar client currently in a manic phase
• C. a client who states they are not interested
• D. a client with dysphagia

Correct answer: C

Rationale: The correct answer is a client who states they are not interested. While lack of interest can hinder learning motivation, it is not a physical or mental barrier that directly impacts the learning process. On the other hand, a client who took Ambien� an hour ago may experience drowsiness or impaired cognitive function, affecting their ability to learn. A bipolar client in a manic phase may exhibit symptoms such as racing thoughts, distractibility, and impulsivity, making it challenging for them to focus and engage in the learning process. A client with dysphagia may have difficulty swallowing, which can interfere with their ability to take oral medications or participate in activities that involve swallowing.

4. A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm. The nurse correctly documents the finding as:

• A. increased ferning capacity.
• B. lack of ferning.
• C. spinnbarkheit.
• D. inhospitable.

Correct answer: C

Rationale: The nurse should document the finding as 'spinnbarkheit.' Spinnbarkheit is the term used to describe the clear, thin, and elastic cervical mucus that can be stretched 8-10 cm, indicating ovulation. It helps couples determine the most fertile period for conception. Ferning capacity or crystallization increases as ovulation approaches, but it requires microscopic examination to be confirmed. Lack of ferning cannot be determined without such examination. 'Inhospitable' cervical mucus refers to patterns that prohibit sperm motility, caused by various factors like hormone levels or infection. These conditions cannot be assessed based solely on the description provided in the question.

5. During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client?

• A. 'When was your last gynecological checkup?'
• B. 'Have you been engaging in unprotected sexual intercourse?'
• C. Don't worry about the discharge. Some vaginal discharge is normal.'
• D. 'I need some more information about the discharge. What color is it?'

Correct answer: D

Rationale: If the client reports having vaginal drainage and concerns about a possible STI, it is essential for the nurse to gather more information about the discharge. Asking about the color of the discharge helps in determining its characteristics, which can be crucial in identifying potential causes. The color, consistency, odor, and associated symptoms can provide valuable insights into the underlying issue. Statements A and B are relevant questions but not as immediate or specific to addressing the client's concern about the discharge. Statement C dismisses the client's worries and does not encourage further assessment, which is not appropriate in this context.

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