Nursing Elites

1. When performing an abdominal assessment on a client, what action should the nurse take first?

• A. Palpate the abdomen
• B. Auscultate bowel sounds
• C. Inspect the abdomen
• D. Percuss the abdomen

Correct answer: B

Rationale: The correct answer is to auscultate bowel sounds. This action should be taken first because it ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen (choice C) may provide visual cues but does not address functional assessment. Palpating the abdomen (choice A) should follow auscultation to prevent altering bowel sounds. Percussing the abdomen (choice D) is typically done after auscultation and palpation.

2. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?

• A. Nutritional status
• B. Client's response to pain medication
• C. Daily vital signs
• D. Most recent lab results

Correct answer: B

Rationale: The correct answer is B: Client's response to pain medication. When transferring a client to another unit, it is crucial to communicate how the client is responding to pain medication to ensure continuity of care and appropriate pain management. While nutritional status, daily vital signs, and most recent lab results are important aspects of the client's care, the client's response to pain medication directly impacts their comfort and well-being during the transfer process.

3. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?

• A. Negligence
• B. Assault
• C. Battery
• D. Defamation

Correct answer: A

Rationale: The correct answer is A: Negligence. Negligence in nursing occurs when a healthcare provider fails to take appropriate action that a reasonably prudent provider would take in a similar situation, such as not notifying the provider of changes in a client's condition. In this scenario, the nurse's failure to inform the provider of the client's changed condition constitutes negligence. Choices B, C, and D are incorrect. Assault involves the intentional threat of bodily harm to another person, battery is the intentional harmful or offensive touching of another person without their consent, and defamation is the act of making false statements about someone to a third party that harms that person's reputation.

4. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Avoid discussing the deceased
• B. Encourage the partner to ask for help when needed
• C. Suggest bereavement counseling
• D. Offer to contact family members

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action in this scenario as it promotes healthy coping mechanisms and support during the mourning process. This approach empowers the individual to seek assistance when required, fostering a sense of control and acknowledging the partner's autonomy in dealing with their grief. Avoiding discussing the deceased (Choice A) may hinder the grieving process by suppressing emotions and preventing the partner from expressing their feelings. While suggesting bereavement counseling (Choice C) is important, the immediate support and encouragement to seek help when needed are crucial. Offering to contact family members (Choice D) may not be the most effective step at this stage, as the focus should be on empowering the partner to cope and seek help on their terms.

5. A client with a new diagnosis of hypertension is receiving discharge teaching. What should the nurse emphasize regarding lifestyle changes?

• A. Limit sodium intake to 2 grams per day
• B. Increase fluid intake to 2 liters per day
• C. Avoid potassium-rich foods
• D. Avoid alcohol consumption

Correct answer: B

Rationale: The correct answer is to increase fluid intake to 2 liters per day. Adequate fluid intake helps manage hypertension and prevent fluid retention. Limiting sodium intake, avoiding potassium-rich foods, and abstaining from alcohol are important aspects of managing hypertension; however, in this scenario, emphasizing the increase in fluid intake is crucial for the client's understanding and compliance.

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