Nursing Elites

1. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Palpate the abdomen before auscultation
• B. Inspect the abdomen after palpation
• C. Auscultate before palpation
• D. Start by percussing the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation when performing an abdominal assessment. This sequence is crucial to prevent altering bowel sounds. Starting with palpation (Choice A) can lead to false interpretations of bowel sounds due to stimulation of the intestines. Inspecting the abdomen after palpation (Choice B) can also potentially alter the assessment findings. Starting with percussion (Choice D) is not recommended as it should come after auscultation to further assess underlying structures.

2. A client who is postoperative following abdominal surgery is at risk for constipation due to which behavior?

• A. Increased fiber intake
• B. Decreased fluid intake
• C. Frequent urge suppression
• D. Increased physical activity

Correct answer: B

Rationale: Postoperative clients are at risk for constipation due to various factors, including decreased fluid intake. Insufficient fluid consumption can lead to hardening of stools, making them difficult to pass. Increased fiber intake (choice A) is actually beneficial for preventing constipation as it adds bulk to the stool. Frequent urge suppression (choice C) can contribute to constipation by disrupting normal bowel habits. Increased physical activity (choice D) generally helps promote bowel movements and reduce the risk of constipation.

3. A nurse is planning a community education program about colorectal cancer. What risk factors should the nurse identify as modifiable?

• A. Age and gender
• B. High-fat diet, smoking, alcohol consumption
• C. Ethnicity and race
• D. Exposure to radiation

Correct answer: B

Rationale: The correct answer is B: High-fat diet, smoking, alcohol consumption. These are modifiable risk factors for colorectal cancer as individuals can make lifestyle changes to reduce their risk. Age and gender (choice A) are non-modifiable risk factors. Ethnicity and race (choice C) can influence the risk of colorectal cancer but are not modifiable factors. Exposure to radiation (choice D) is not a common modifiable risk factor for colorectal cancer.

4. A nurse is preparing to administer enteral feedings to a client with an NG tube. Which action should the nurse take first?

• A. Flush the tube with 100 mL of water
• B. Verify tube placement
• C. Elevate the head of the bed
• D. Measure the residual gastric volume

Correct answer: B

Rationale: Verifying tube placement is the priority action the nurse should take before administering enteral feedings. This step ensures that the NG tube is correctly positioned, reducing the risk of complications such as aspiration pneumonia. Flushing the tube with water, elevating the head of the bed, and measuring residual gastric volume are important steps in enteral feeding administration but come after verifying tube placement. Flushing the tube with water helps clear the tubing, elevating the head of the bed reduces the risk of aspiration, and measuring residual gastric volume helps assess the client's tolerance to feedings.

5. A nurse is caring for a client who is postoperative following cataract surgery. The client reports that they do not want to wear their eye shield. What should the nurse do?

• A. Allow the client to make their own decision
• B. Explain the importance of wearing the eye shield
• C. Remove the eye shield and assess the eye
• D. Encourage the client to discuss their concerns

Correct answer: B

Rationale: The correct answer is B: Explain the importance of wearing the eye shield. It is important for the nurse to educate the client on the reasons why wearing the eye shield is crucial post cataract surgery, such as protecting the eye from injury and promoting proper healing. This empowers the client with knowledge and helps them make an informed decision. Choice A is incorrect because the nurse should provide necessary information to ensure the client's safety. Choice C is incorrect as removing the eye shield without proper justification can compromise the client's recovery. Choice D is also incorrect as discussing concerns should come after the client is educated on the importance of the eye shield.

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