Nursing Elites

1. A nurse is preparing to perform an abdominal assessment on a client. Which action should the nurse take first?

• A. Percuss the abdomen
• B. Inspect the abdomen
• C. Auscultate before palpation
• D. Palpate the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation. This ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen is a valid step but not the first. Percussing and palpating should come after auscultation to prevent altering bowel sounds or causing discomfort to the client.

2. A nurse is reviewing a client's health history and identifies urinary incontinence as a risk factor for pressure injuries. What should the nurse include in the plan of care?

• A. Use a heating pad for comfort
• B. Apply a barrier cream to the skin
• C. Reposition the client every 4 hours
• D. Change the client's position every 2 hours

Correct answer: C

Rationale: The correct answer is to reposition the client every 4 hours. Repositioning the client helps prevent pressure injuries caused by urinary incontinence by relieving pressure on vulnerable areas of the skin. Choice A, using a heating pad for comfort, is not directly related to preventing pressure injuries. Choice B, applying a barrier cream to the skin, may help protect the skin but does not address the underlying cause of pressure injuries. Choice D, changing the client's position every 2 hours, is more frequent than necessary and may not be as effective in preventing pressure injuries as repositioning every 4 hours.

3. A healthcare professional is planning to administer an intramuscular injection to a client. What muscle should the healthcare professional choose to avoid injury?

• A. Deltoid
• B. Ventrogluteal
• C. Rectus femoris
• D. Dorsogluteal

Correct answer: B

Rationale: The ventrogluteal muscle is the preferred site for intramuscular injections to avoid injury. Choosing the ventrogluteal site reduces the risk of injury to major nerves and blood vessels, unlike the deltoid, rectus femoris, or dorsogluteal sites. The deltoid muscle is commonly used for vaccines but has a higher risk of injury due to its proximity to the radial nerve. The rectus femoris muscle is not recommended for intramuscular injections due to its location and the risk of injury. The dorsogluteal site is also not recommended as it poses a risk of injury to the sciatic nerve and superior gluteal artery.

4. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What lifestyle modification should the nurse emphasize?

• A. Decrease potassium intake
• B. Increase fluid intake to 2 liters per day
• C. Avoid foods high in calcium
• D. Increase sodium intake

Correct answer: B

Rationale: The correct lifestyle modification that the nurse should emphasize for a client with hypertension is to increase fluid intake to 2 liters per day. Proper hydration helps manage hypertension by supporting kidney function in regulating blood pressure and by diluting sodium levels in the body. Decreasing potassium intake (Choice A) is not recommended, as potassium-rich foods like fruits and vegetables are beneficial for blood pressure control. Avoiding foods high in calcium (Choice C) is not directly related to managing hypertension, and increasing sodium intake (Choice D) is contraindicated as excess sodium can elevate blood pressure.

5. A nurse is preparing to perform a focused respiratory assessment on a client with COPD. What is an expected finding?

• A. Normal respiratory rate
• B. Nasal flaring
• C. Decreased breath sounds
• D. Increased breath sounds

Correct answer: B

Rationale: Nasal flaring is an expected finding in clients with COPD who are experiencing respiratory distress. Nasal flaring is a sign of increased work of breathing and respiratory distress, commonly seen in clients with COPD exacerbation. Choices A, C, and D are incorrect. A normal respiratory rate would not be an expected finding in a client with COPD, as they often have an increased respiratory rate. Decreased breath sounds could indicate diminished airflow but are not typically a common finding in COPD. Increased breath sounds are not typical in COPD and could indicate other conditions like pneumonia.

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