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 healthcare professional is reviewing a client's medication prescription, which reads, 'digoxin 0.25 by mouth every day.' Which of the following components of the prescription should the healthcare professional question?

• A. the medication
• B. the route
• C. the dose
• D. the frequency

Correct answer: C

Rationale: The healthcare professional should question the dose indicated in the prescription. In this case, '0.25' is incomplete without a unit of measurement, such as mg (milligrams). Without a specified unit, the dose lacks the necessary information for accurate administration. Choices A, B, and D are not incorrect components to question in medication prescriptions; however, in this scenario, the incompleteness of the dose is the most critical concern that needs clarification to ensure safe and effective medication administration.

3. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

• A. Discontinue the machine and measure the blood pressure manually every 15 minutes.
• B. Adjust the machine settings.
• C. Clean the machine to ensure accuracy.
• D. Increase the frequency of the readings.

Correct answer: B

Rationale: In this scenario, the nurse should adjust the machine settings. If the electronic blood pressure machine is providing varied intervals and inconsistent readings, it indicates a potential malfunction. Changing the settings may help correct the issue and ensure accurate measurements. Discontinuing the machine and measuring manually every 15 minutes (Choice A) may be time-consuming and impractical. Cleaning the machine (Choice C) is important for routine maintenance but may not address the current issue of varied intervals and inconsistent readings. Increasing the frequency of the readings (Choice D) does not address the problem of inaccurate measurements caused by the malfunctioning machine.

4. A client is being treated for diabetic ketoacidosis (DKA). Which laboratory value would be most concerning?

• A. Blood glucose of 350 mg/dL
• B. Serum bicarbonate of 18 mEq/L
• C. Arterial pH of 7.20
• D. Serum potassium of 5.5 mEq/L

Correct answer: C

Rationale: In a client with diabetic ketoacidosis (DKA), the most concerning laboratory value is an arterial pH of 7.20. An arterial pH of 7.20 indicates severe acidosis, which is a critical condition requiring immediate intervention. This pH level reflects a significant imbalance in the body's acid-base status, potentially leading to serious complications. High blood glucose levels (choice A) are expected in DKA but do not directly indicate the severity of acidosis. A serum bicarbonate level of 18 mEq/L (choice B) is low but not as immediately critical as a pH of 7.20. Serum potassium of 5.5 mEq/L (choice D) is elevated, which can occur in DKA due to insulin deficiency, but it is not the most concerning value in this scenario.

5. A client has been admitted to the hospital with severe diarrhea. The nurse should monitor the client for which complication?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: Severe diarrhea can lead to metabolic acidosis due to the loss of bicarbonate. When there is excessive loss of bicarbonate through diarrhea, the pH of the blood decreases, leading to metabolic acidosis. Metabolic alkalosis (Choice B) is not typically associated with severe diarrhea as it involves elevated pH and bicarbonate levels. Hyperkalemia (Choice C) is less likely with severe diarrhea as potassium is often lost along with fluids. Hypercalcemia (Choice D) is not a common complication of severe diarrhea; instead, hypocalcemia may occur due to malabsorption of calcium.

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