Nursing Elites

1. During an admission assessment, a healthcare professional finds a client's radial pulse rate to be 68/min and the simultaneous apical pulse to be 84/min. What is the client’s pulse deficit (per minute)?

• A. 16
• B. 12
• C. 6
• D. 14

Correct answer: A

Rationale: The pulse deficit is calculated by finding the difference between the apical and radial pulse rates. In this case, the difference is 84 - 68 = 16. This indicates that there is a pulse deficit of 16 beats per minute. Choices B, C, and D are incorrect as they do not accurately reflect the difference between the two pulse rates.

2. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?

• A. Offer small sips of water through a straw
• B. Place tongue blade on back half of tongue
• C. Use a penlight to observe back of the oral cavity
• D. Auscultate breath sounds after the client swallows

Correct answer: B

Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.

3. What advice should the client be given if they are feeling dizzy upon standing after taking a diuretic for hypertension?

• A. Avoid standing up too quickly.
• B. Increase fluid intake to stay hydrated.
• C. Eat more salt to help retain fluids.
• D. Wear compression stockings during the day.

Correct answer: A

Rationale: The correct advice for a client feeling dizzy upon standing after taking a diuretic for hypertension is to avoid standing up too quickly. Diuretics can lead to orthostatic hypotension, causing dizziness upon sudden position changes. Increasing fluid intake can exacerbate the issue by further lowering blood pressure. Eating more salt might counteract the diuretic's effects but is not the primary intervention for orthostatic hypotension. Compression stockings are more relevant for venous insufficiency than for orthostatic hypotension.

4. During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?

• A. Fat
• B. Fluid
• C. Flatus
• D. Hernias

Correct answer: D

Rationale: The correct answer is 'Hernias.' Abdominal distention with a midline protrusion, taut skin, and no involvement of the flanks is characteristic of hernias. Hernias are caused by a weakness in the abdominal wall, allowing organs or tissues to protrude through. Fluid accumulation (ascites) typically presents with a more generalized distention, while fat accumulation may cause more diffuse distension rather than a focal midline protrusion. Flatus, or gas, would not typically present with a visible midline protrusion and taut skin like hernias.

5. When assessing the respiratory system for complications of immobility, what action should the nurse take?

• A. Inspect chest wall movements primarily during the expiratory cycle.
• B. Auscultate the entire lung region to assess lung sounds.
• C. Focus auscultation on the upper lung fields.
• D. Assess the patient at least every 4 hours.

Correct answer: B

Rationale: The correct action for the nurse when assessing the respiratory system for complications of immobility is to auscultate the entire lung region. This approach allows the nurse to identify any diminished breath sounds, crackles, or wheezes that may indicate respiratory issues. Inspecting chest wall movements primarily during the expiratory cycle (Choice A) may not provide a comprehensive assessment of lung sounds. Focusing auscultation on the upper lung fields (Choice C) may miss important findings in the lower lung fields. Assessing the patient at least every 4 hours (Choice D) is important for monitoring overall patient condition but does not specifically address the assessment of respiratory complications related to immobility.

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