Nursing Elites

1. How should a nurse listen to the breath sounds of a client?

• A. Ask the client to lie prone.
• B. Ask the client to breathe in and out through the nose.
• C. Hold the bell of the stethoscope lightly against the chest.
• D. Listen for at least one full respiration in each location on the chest.

Correct answer: D

Rationale: To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment. Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.

2. The nurse is caring for a female client who has recently been diagnosed with cancer and will soon begin chemotherapy. Which of these statements would require additional follow-up and education?

• A. I will be most susceptible to an infection between 7 and 12 days after chemotherapy.
• B. I should try to get my annual teeth cleaning in before beginning chemotherapy.
• C. I should wait until all my hair falls out to purchase a wig.
• D. I should try to drink 8-10 glasses of water a day.

Correct answer: C

Rationale: This client is at risk for altered body image due to chemotherapy-induced hair loss. A wig can assist in coping with this change. It is advisable for the client to shop for a wig before hair loss occurs to better match color and style. Waiting until all hair falls out may lead to stress and limited options in finding a suitable wig. Choices A, B, and D are accurate. Understanding the timing of susceptibility to infection, maintaining oral health before chemotherapy, and staying hydrated are important aspects of care during chemotherapy. Therefore, the statement 'I should wait until all my hair falls out to purchase a wig' requires additional follow-up and education.

3. When inspecting the ears for cerumen impaction, the nurse checks for which finding?

• A. Redness and swelling of the tympanic membrane
• B. An external auditory canal that is longer than normal
• C. The presence of edema in the external auditory canal
• D. A yellowish or brownish waxy material in the external auditory canal

Correct answer: D

Rationale: When inspecting the ears for cerumen impaction, the nurse should look for a yellowish or brownish waxy material in the external auditory canal. Cerumen, also known as ear wax, is a secretion that can become impacted due to various reasons. It is produced by the vestigial apocrine sweat glands in the external ear canal. Cerumen may partially obscure the eardrum or totally occlude the ear canal. The other options, redness and swelling of the tympanic membrane, an external auditory canal that is longer than normal, and the presence of edema in the external auditory canal, are not indicative findings of cerumen impaction.

4. While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?

• A. Trochlear nerve
• B. Abducens nerve
• C. Trigeminal nerve
• D. Oculomotor nerve

Correct answer: C

Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.

5. A client is scheduled to undergo a Papanicolaou (Pap) test in 1 week. Which statement does the nurse make to the client?

• A. 'If you are menstruating, use pads instead of a tampon.'
• B. 'Avoid intercourse for 24 hours before the scheduled examination.'
• C. 'Get a douching kit from the pharmacy and douche 2 hours before the examination.'
• D. 'If you are having a vaginal discharge, obtain a sample of the discharge for inspection.'

Correct answer: B

Rationale: The correct answer is to 'Avoid intercourse for 24 hours before the scheduled examination.' The Pap test is used to screen for cervical cancer. It is not performed during menstruation or if a heavy infectious discharge is present. Before the test, the client should not douche, have intercourse, or insert anything into the vagina within 24 hours. Instructing the client to use pads instead of a tampon when menstruating can interfere with the test results due to the presence of blood. Douching before the exam is discouraged as it can alter the cervical cells' appearance, affecting the test's accuracy. Obtaining a sample of vaginal discharge for inspection is not a standard pre-Pap test instruction and is unnecessary for the test.

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