Nursing Elites

1. During a physical assessment of adult clients, which of the following techniques should the nurse use?

• A. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client experiencing pain.
• B. Palpate the client's abdomen before auscultating bowel sounds.
• C. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.
• D. Obtain an apical heart rate by auscultating at the third intercostal space to the left of the sternum.

Correct answer: B

Rationale: When performing a physical assessment, it is essential to palpate the client's abdomen before auscultating bowel sounds. This sequence helps prevent altering bowel sound results due to the pressure applied during palpation. Choice A is incorrect because the FLACC pain rating scale is typically used for nonverbal or pediatric clients, not adults. Choice C is incorrect because the bladder of the blood pressure cuff should surround about 80% of the client's arm circumference, not the bladder of the cuff itself. Choice D is incorrect because to obtain an apical heart rate, auscultation should be done at the fifth intercostal space at the midclavicular line, not at the third intercostal space to the left of the sternum.

2. What is the difference between the amounts that were budgeted for specific revenue or cost and the actual revenue or cost that resulted during the course of activities?

• A. Budget
• B. Variable
• C. Variance
• D. Premiums

Correct answer: C

Rationale: The correct answer is C, Variance. Variance represents the distinction between the planned budgeted amount for a particular revenue or cost and the actual amount that occurred during the activities. In financial management, variance analysis is crucial for assessing performance and identifying areas that deviate from the budgeted expectations. Choice A, 'Budget,' is incorrect as it refers to the planned amount rather than the difference between planned and actual amounts. Choice B, 'Variable,' does not specifically address the comparison between budgeted and actual figures. Choice D, 'Premiums,' is unrelated to the concept of comparing budgeted and actual values in the context of financial analysis.

3. A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

• A. Activate the emergency fire alarm.
• B. Extinguish the fire.
• C. Evacuate the client.
• D. Confine the fire.

Correct answer: D

Rationale: In this situation, the nurse's priority should be to confine the fire. By confining the fire, the nurse can prevent it from spreading further and causing more harm. Activating the emergency fire alarm (choice A) is important but should come after confining the fire. Extinguishing the fire (choice B) might not be safe for the nurse to do without proper equipment and training. Evacuating the client (choice C) can be considered once the fire is confined to ensure the client's safety.

4. A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

• A. Make sure the enteral formula is at room temperature.
• B. Wipe the top of the formula can with alcohol.
• C. Rinse the feeding bag with water between feedings.
• D. Tell the client to keep the head of the bed elevated at least 30�

Correct answer: B

Rationale:

5. Factors that may contribute to workplace violence in a health care setting include:

• A. Lack of armed security
• B. Continuous loud noises and/or poorly monitored entrances
• C. Poor staff interactions
• D. Tense shoulders and clenched fists

Correct answer: B

Rationale: The correct answer is B. Continuous loud noises and poorly monitored entrances can contribute to workplace violence by creating a chaotic environment that can escalate tensions. Factors like lack of armed security (choice A) may not be as significant in triggering violence as environmental factors. Poor staff interactions (choice C) can contribute to a negative work culture but may not directly lead to violence. Tense shoulders and clenched fists (choice D) may indicate stress or anger in an individual but are not factors that contribute to workplace violence in general.

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