Nursing Elites

1. A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client?

• A. Supine
• B. Standing
• C. Lithotomy
• D. Left lateral

Correct answer: D

Rationale: For a rectal examination in a female client, the nurse should assist the client into the left lateral position. This position allows easier access to the rectal area, facilitating the examination. The lithotomy position is used for examining the genitalia and rectum in females, not solely for a rectal examination. The standing position is not appropriate for a rectal examination as it does not provide the necessary access. The supine position would hinder the effectiveness of a rectal examination as it does not optimize access to the rectal area.

2. While assessing for costovertebral angle tenderness, a nurse percusses the area, and the client complains of sharp pain. The nurse interprets this finding as most indicative of which disorder?

• A. Liver enlargement
• B. Ovarian infection
• C. Spleen enlargement
• D. Kidney inflammation

Correct answer: D

Rationale: When assessing for costovertebral angle tenderness, sharp pain on percussion of the area indicates inflammation of the kidney or paranephric area. The correct technique involves placing one hand over the 12th rib, at the costovertebral angle, and thumping that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver enlargement, or spleen enlargement are not associated with the costovertebral angle tenderness. Therefore, the correct answer is kidney inflammation.

3. The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which observation is a sign of physical readiness?

• A. The child no longer has temper tantrums.
• B. The child can remove his or her own clothing.
• C. The child has been walking for 2 years.
• D. The child can eat using a fork and knife.

Correct answer: B

Rationale: Signs of physical readiness for toilet training include the child's ability to remove his or her own clothing. This ability indicates the child has developed the necessary fine motor skills to manage clothing during toilet training. The other choices are incorrect because temper tantrums, walking for a specific period, and using utensils are not indicators of physical readiness for toilet training.

4. What is a chemical reaction between drugs before their administration or absorption known as?

• A. a drug incompatibility
• B. a side effect
• C. an adverse event
• D. an allergic response

Correct answer: A

Rationale: A chemical reaction between drugs before their administration or absorption is termed a drug incompatibility. This phenomenon commonly occurs when drug solutions are mixed before intravenous administration but can also happen with orally administered drugs. Choices B, C, and D are incorrect because side effects, adverse events, and allergic responses typically occur after the drugs have been administered and absorbed, not before.

5. When determining a fetal heart rate (FHR) and noting accelerations from the baseline rate when the fetus is moving, a nurse interprets this finding as:

• A. A reassuring sign
• B. An indication of the need to contact the physician
• C. An indication of fetal distress
• D. A nonreassuring sign

Correct answer: A

Rationale: When a nurse notes accelerations from the baseline rate of the fetal heart rate, particularly when they occur with fetal movement, it is considered a reassuring sign. This indicates a healthy response to fetal activity. Reassuring signs in FHR monitoring include an average rate between 120 and 160 beats/min at term, a regular rhythm with slight fluctuations, accelerations from the baseline rate (often associated with fetal movement), and the absence of decreases from the baseline rate. Choices B, C, and D are incorrect because accelerations in FHR with fetal movement are not indicative of the need to contact the physician, fetal distress, or a nonreassuring sign. These signs would typically be associated with other abnormal FHR patterns that would warrant further assessment and intervention.

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