Nursing Elites

1. During an assessment, a nurse is evaluating the breath sounds of an adult client diagnosed with pneumonia. Which of the following actions should the nurse take?

• A. Follow a systematic pattern from side-to-side moving down the client’s chest.
• B. Ask the client to breathe in deeply through their nose.
• C. Instruct the client to sit upright with their head slightly tilted backward.
• D. Place the diaphragm of the stethoscope on the client’s chest.

Correct answer: A

Rationale: When assessing breath sounds in a client with pneumonia, the nurse should follow a systematic pattern from side-to-side moving down the client’s chest. This approach ensures a comprehensive evaluation of breath sounds across different lung fields. Asking the client to breathe in deeply through their nose (Choice B) is not necessary for assessing breath sounds. Instructing the client to sit upright with their head slightly tilted backward (Choice C) is not directly related to assessing breath sounds and may not be required. Placing the diaphragm of the stethoscope on the client’s chest (Choice D) is not the correct technique for auscultating breath sounds, as the diaphragm should be used for this purpose.

2. A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team?

• A. Social worker
• B. Certified nursing assistant
• C. Occupational therapist
• D. Speech-language pathologist

Correct answer: D

Rationale: The correct answer is D, Speech-language pathologist. Speech-language pathologists specialize in assessing and treating dysphagia, which is a common issue following a cerebrovascular accident. They are trained to evaluate swallowing function and provide appropriate interventions to help clients improve their ability to swallow safely. Choice A, Social worker, is incorrect as their role does not typically involve addressing dysphagia specifically. Choice B, Certified nursing assistant, is not the appropriate professional to address dysphagia concerns as they do not have the training or scope of practice for this specialized area. Choice C, Occupational therapist, focuses more on activities of daily living and functional abilities rather than the specialized treatment of dysphagia.

3. During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

• A. Mongolian spots are a normal finding in dark-skinned infants.
• B. Port wine stains are typically associated with other malformations.
• C. Telangiectatic nevi are normal and will disappear as the baby grows.
• D. The child is too young for surgical removal of these at this time.

Correct answer: C

Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.

4. A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurse's priority?

• A. Extinguish the fire.
• B. Activate the fire alarm.
• C. Move clients who are nearby.
• D. Close all open doors on the unit.

Correct answer: B

Rationale: In a fire emergency, the nurse's priority is to activate the fire alarm. This action alerts others to the emergency, initiates the evacuation process, and ensures everyone's safety. Extinguishing the fire can be dangerous and should be left to trained personnel. Moving clients who are nearby might delay the activation of the alarm and can put the nurse and clients at risk. Closing all open doors on the unit is important to contain the fire but should not take precedence over alerting others through the fire alarm system.

5. A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client moves the walker ahead 25.4 cm with each step
• B. The client picks up the walker with each step
• C. The client stands with elbows slightly bent while holding the walker
• D. The client stoops slightly forward when moving the walker

Correct answer: C

Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.

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