Nursing Elites

1. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?

• A. Collaborating with the client to establish healthcare goals
• B. Reviewing the client's medical record history
• C. Explaining the purpose of administered medications to the client
• D. Rapidly resetting priorities for client care based on changes in the client's condition

Correct answer: D

Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.

2. A physician's order instructs a nurse to take a temperature at the axilla. Where would the nurse place the thermometer?

• A. In the rectum
• B. In the mouth
• C. On the temples
• D. In the armpit

Correct answer: A

Rationale: When a physician's order specifies taking a temperature at the axilla, the nurse should place the thermometer in the armpit. The axilla is the anatomical area of the armpit located under the arms, proximal to the trunk. Placing the thermometer in the rectum (Choice A) is used for rectal temperature measurements, in the mouth (Choice B) for oral temperature measurements, and on the temples (Choice C) is not a common site for temperature assessment. Therefore, the correct placement based on the given instruction is in the armpit.

3. A physician asks you to place the patient with his dorsal side facing the exam table. Which of the following accurately describes how the patient is positioned?

• A. The patient is lying prone.
• B. The patient is lying supine.
• C. The patient is lying in the recovery position.
• D. The patient is lying on his stomach.

Correct answer: B

Rationale: When the physician asks for the patient to be placed with their dorsal side facing the exam table, it means the patient should be lying on their back. This position is known as the supine position, where the patient's back is on the table, facing up towards the ceiling. Choice A, 'The patient is lying prone,' is incorrect as the prone position is when the patient is lying face down. Choice C, 'The patient is lying in the recovery position,' is incorrect as the recovery position is a lateral position typically used in first aid. Choice D, 'The patient is lying on his stomach,' is incorrect as it describes the prone position, not the supine position as required in this scenario.

4. The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed?

• A. Avoid palpating reportedly “tender” areas as this may cause pain.
• B. Palpate tender areas quickly to minimize patient discomfort.
• C. Initiate the assessment with deep palpation while encouraging the patient to relax and take deep breaths.
• D. Begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch.

Correct answer: D

Rationale: The correct approach is to begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch. This allows the nurse to first assess surface features before proceeding to deeper palpation. Starting with light palpation also helps the patient become more comfortable with being touched, creating a smoother examination experience. Palpating tender areas quickly, as suggested in choice B, can increase patient discomfort. Deep palpation, as in choice C, is typically performed after light palpation to avoid discomfort and ensure proper assessment. Avoiding palpation of tender areas first, as in choice A, helps prevent causing unnecessary pain and should be done towards the end of the assessment.

5. When evaluating the temperature of older adults, what aspect should the healthcare provider remember about an older adult's body temperature?

• A. The body temperature of the older adult is lower than that of a younger adult.
• B. An older adult's body temperature is approximately the same as that of a young child.
• C. Body temperature varies based on the type of thermometer used.
• D. In older adults, body temperature can fluctuate widely due to less effective heat control mechanisms.

Correct answer: A

Rationale:

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