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. The LPN is preparing a client for discharge, and the discharge medications include phenobarbital. Which of these client statements would indicate a need for reinforced teaching about this medication?

• A. "I will need to avoid eating excessive leafy greens."?
• B. "It's best to take this medication with food."?
• C. "I can't wait to get back to my nightly glass of wine."?
• D. "I should try to take this medication at the same time every day."?

Correct answer: C

Rationale: The correct answer is, "I can't wait to get back to my nightly glass of wine,"? as phenobarbital should not be taken with alcohol as it is a barbiturate. Alcohol may increase the sedative effect, posing risks to the patient's safety. Choice A, "I will need to avoid eating excessive leafy greens,"? is unrelated to phenobarbital and not a cause for reinforced teaching. Choice B, "It's best to take this medication with food,"? is a general instruction and not specific to phenobarbital. Choice D, "I should try to take this medication at the same time every day,"? is a common recommendation for medication adherence but does not highlight a specific concern related to phenobarbital.

3. A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?

• A. Stethoscope
• B. Doppler transducer
• C. Fetoscope
• D. Pulse oximetry on the client and a fetoscope

Correct answer: B

Rationale: To assess the fetal heart rate of a client who is 14 weeks pregnant, the nurse should use a Doppler transducer. Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation, making it the most appropriate choice for this scenario. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds, so it is an incorrect choice in this context.

4. A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by performing which action?

• A. Placing a tape measure around the widest point of the lower leg
• B. Measuring 2 inches above the knee and placing the tape measure around the client's leg at this point
• C. Measuring 2 inches above the ankle and placing the tape measure around the client's leg at this point
• D. Measuring 2 inches below the patella and placing the tape measure around the client's leg at this point

Correct answer: A

Rationale: To measure a client's calf circumference accurately, a nurse should place a non-stretchable tape measure around the widest point of the lower leg. It is crucial to ensure that the tape measure is positioned at the same number of centimeters down from a specific landmark, such as the patella, on both legs for consistency. Placing the tape measure 2 inches above the knee (Option B), 2 inches above the ankle (Option C), or 2 inches below the patella (Option D) would not provide an accurate measurement of the calf circumference. Therefore, these options are incorrect choices.

5. A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?

• A. Coffee
• B. A tuning fork
• C. A wisp of cotton
• D. An ophthalmoscope

Correct answer: C

Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse uses a wisp of cotton to test the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a non-noxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Choice A, 'Coffee,' is incorrect because it is used to present non-noxious aromatic substances to assess cranial nerve I. Choice B, 'A tuning fork,' is used to assess the function of cranial nerve VIII (acoustic nerve). Choice D, 'An ophthalmoscope,' is used to assess the internal structures of the eye, not cranial nerve I.

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