Nursing Elites

1. A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?

• A. Left upper quadrant
• B. Left lower quadrant
• C. Right upper quadrant
• D. Right lower quadrant

Correct answer: D

Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there. Then, the nurse proceeds to listen for bowel sounds in the other quadrants. Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.

2. A nurse in the newborn nursery, assisting with data collection for a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant at which location?

• A. In the axillary area
• B. At the level of the nipples
• C. Two inches below the nipples
• D. At the level of the umbilicus

Correct answer: B

Rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head circumference. The average chest circumference is 30.5 to 33 cm (12-13 inches). When there is molding of the head, the head and chest measurements may be equal at birth. Placing the tape measure at the level of the nipples ensures accuracy and consistency in newborn assessment. Options A, C, and D are incorrect as the chest circumference is specifically measured at the level of the nipples to obtain precise measurements.

3. A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?

• A. The client has a fever.
• B. The skin temperature is normal.
• C. The client needs to drink additional fluids.
• D. The client needs to have the blanket removed.

Correct answer: B

Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.

4. Health promotion activities are designed to help clients:

• A. reduce the risk of illness
• B. maintain maximal function
• C. promote healthy habits related to healthcare
• D. all of the above

Correct answer: D

Rationale: Health promotion activities encompass a broad range of interventions aimed at enhancing overall well-being. These activities not only focus on reducing the risk of illness but also on maintaining maximal function and promoting healthy habits related to healthcare. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all integral components of health promotion strategies, emphasizing the multidimensional approach required to support clients in achieving optimal health outcomes.

5. When performing an eye examination, which area can a healthcare provider best visualize using an ophthalmoscope?

• A. Iris
• B. Cornea
• C. Optic disc
• D. Conjunctiva

Correct answer: C

Rationale: An ophthalmoscope is a tool used to visualize the internal structures of the eye during an examination. The optic disc, located on the internal surface of the retina, can be best visualized using an ophthalmoscope. The iris, cornea, and conjunctiva are superficial structures that can be examined without the need for an ophthalmoscope. Therefore, the correct answer is the optic disc. Choices A, B, and D are incorrect because they are external structures that can be examined directly without the use of an ophthalmoscope.

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