Nursing Elites

1. A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be?

• A. Harsh
• B. Hollow
• C. Tubular
• D. Rustling

Correct answer: D

Rationale: The correct answer is D: 'Rustling.' Vesicular breath sounds are described as rustling and resemble the sound of wind blowing through trees. Harsh, hollow, and tubular sounds are associated with bronchial (tracheal) breath sounds, not vesicular breath sounds. Harsh sounds are high-pitched, hollow sounds are reverberating, and tubular sounds are like blowing air into a tube. Therefore, options A, B, and C are incorrect descriptions of vesicular breath sounds and are more characteristic of bronchial breath sounds.

2. A nurse palpates a client’s radial pulse, noting the rate, rhythm, and force, and concludes that the client’s pulse is normal. Which notation would the nurse make in the client’s record to document the force of the client’s pulse?

• A. 4+
• B. 3+
• C. 2+
• D. 1+

Correct answer: C

Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+ for a bounding pulse, 3+ for an increased pulse, 2+ for a normal pulse, and 1+ for a weak pulse. In this case, the nurse would grade the client’s pulse as 2+ based on the description of a normal pulse. Therefore, the correct notation for the force of the client’s pulse is '2+' as it indicates a normal pulse. Choices A, B, and D are incorrect as they represent different levels of pulse force that do not align with the description given in the scenario.

3. During a genital examination of a male client, a nurse notices wrinkled skin on the penis and scrotum. What should the nurse do based on this finding?

• A. Documents the normal finding
• B. Checks for penile discharge, as this indicates infection
• C. Palpates for a mass in the scrotum, as wrinkling suggests the presence of one
• D. Obtains additional subjective data from the client, focusing on the scrotal abnormality

Correct answer: A

Rationale: The penile skin typically appears wrinkled and hairless, without lesions, during a normal examination. Also, the scrotal skin naturally has a wrinkled appearance known as rugae. It is common for the left half of the scrotum to be positioned lower than the right, indicating normal asymmetry. Given these normal variations, the nurse should document the finding of wrinkled skin on the penis and scrotum. Checking for penile discharge or palpating for a mass in the scrotum is not indicated based on the presence of wrinkled skin, as this is a normal finding. Obtaining additional subjective data focusing on a scrotal abnormality is unnecessary since the wrinkled appearance is typical.

4. How should a client's neck be positioned for palpation of the thyroid?

• A. flexed toward the side being examined
• B. hyperextended directly backward
• C. flexed away from the side being examined
• D. flexed directly forward

Correct answer: A

Rationale: The correct way to position a client's neck for palpation of the thyroid is to have it flexed toward the side being examined. This positioning helps to better access and palpate the thyroid gland. Option B, hyperextending the neck directly backward, is incorrect as it can make palpation more difficult and uncomfortable for the client. Option C, flexing the neck away from the side being examined, is also incorrect as it may obscure the thyroid gland, making it harder to palpate. Option D, flexing the neck directly forward, is not ideal for thyroid palpation as it does not provide the best access to the gland.

5. 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.

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