Nursing Elites

1. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?

• A. Perform deep palpation at the end of the admission assessment
• B. Auscultate the client’s abdomen before palpation
• C. Begin palpation of the abdomen at the site of pain
• D. Assess the client’s bowel sounds using the bell of the stethoscope

Correct answer: B

Rationale: Auscultating the abdomen before palpation is the correct action for the nurse to take in this scenario. This approach helps to assess bowel sounds accurately and prevents the alteration of bowel sounds that can occur due to palpation. By auscultating first, the nurse can gather important information about bowel function before proceeding with the palpation. Choice A is incorrect because deep palpation should be avoided initially, especially in a client reporting abdominal pain, as it may cause discomfort or potential harm. Choice C is incorrect as palpation should typically start away from the site of pain to prevent exacerbating discomfort. Choice D is incorrect because assessing bowel sounds with the bell of the stethoscope is not the initial step recommended when a client reports abdominal pain; auscultation should be performed with the diaphragm of the stethoscope first.

2. A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging?

• A. Slower light touch sensation
• B. Some vision and hearing decline
• C. Slower fine finger movement
• D. Some short-term memory decline

Correct answer: B

Rationale: As individuals age, it is common to experience changes in vision and hearing, leading to some decline in these senses. Slower light touch sensation and slower fine finger movement are also typical findings associated with aging. However, some short-term memory decline is more closely related to cognitive aging rather than typical age-related changes in the neurologic system. Therefore, the correct answer is the decline in vision and hearing. Decreased risk of depression is not a typical finding in aging; in fact, the risk of depression may increase as individuals age.

3. Upon admission to the hospital, a client presents with decreased circulation in the left leg. What is the most important initial nursing action during the assessment?

• A. Assess the client's mobility
• B. Evaluate the pedal pulses
• C. Monitor skin temperature
• D. Check for swelling

Correct answer: B

Rationale: When a client is admitted with decreased circulation in the left leg, the most critical initial nursing action is to evaluate the pedal pulses. Pedal pulses provide essential information about the circulation status in the affected leg. Assessing the client's mobility (Choice A) is important but not as crucial as evaluating pedal pulses in this scenario. Monitoring skin temperature (Choice C) and checking for swelling (Choice D) are also relevant, but they are secondary to evaluating pedal pulses since the latter directly assesses the circulation in the affected limb.

4. When providing mouth care for an unconscious client, what action should the nurse take?

• A. Turn the client’s head to the side.
• B. Place two fingers in the client’s mouth to open it.
• C. Brush the client’s teeth once per day.
• D. Inject mouth rinse into the center of the client’s mouth.

Correct answer: A

Rationale: When providing mouth care for an unconscious client, the nurse should turn the client’s head to the side. This action helps prevent aspiration by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Placing fingers into the client’s mouth can be dangerous and may cause injury. Brushing the client’s teeth only once a day may not be sufficient for proper oral hygiene care. Injecting mouth rinse into the center of the mouth is not recommended and can potentially lead to aspiration. Therefore, the correct action for the nurse to take is to turn the client’s head to the side.

5. The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take?

• A. Directly address the child instead of the mother.
• B. Continue asking the mother questions about the child.
• C. Request another nurse to interview the mother now.
• D. Politely ask the mother to look at you when answering.

Correct answer: B

Rationale: In this scenario, the LPN should continue asking the mother questions about the child. The mother's behavior of looking at the floor may be a cultural practice, such as avoiding direct eye contact, which should be respected. By maintaining the conversation with the mother, the nurse acknowledges and respects her communication style, fostering trust and open dialogue. Option A is not the best choice as it may disregard the cultural context and the importance of the mother's input. Option C is unnecessary as the LPN can effectively handle the situation. Option D could be perceived as insensitive and may disrupt the rapport between the nurse and the mother.

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