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 assigned to a manipulative client for 5 days and becomes aware of feelings of reluctance to interact with the client. What should the nurse do next?

• A. Discuss the feelings of reluctance with an objective peer or supervisor
• B. Limit contacts with the client to avoid reinforcement of the manipulative behavior
• C. Confront the client about the negative effects of behaviors on other clients and staff
• D. Develop a behavior modification plan that will promote more functional behavior

Correct answer: A

Rationale: It is important for the nurse to address their feelings of reluctance when dealing with a manipulative client by discussing them with an objective peer or supervisor. This action can provide valuable insight and support for managing the nurse-client relationship. Choice B should be avoided as limiting contacts with the client may not address the underlying issues and could potentially harm the therapeutic relationship. Choice C is confrontational and may escalate the situation rather than resolve it. Choice D, while important, should come after addressing the nurse's feelings and seeking support.

3. While auscultating the anterior chest of a client newly admitted to a medical-surgical unit, a nurse listens to the audio clip of breath sounds through her stethoscope. What type of breath sounds does the nurse hear?

• A. Crackles
• B. Rhonchi
• C. Friction rub
• D. Normal breath sounds

Correct answer: D

Rationale: The correct answer is D: Normal breath sounds. In the scenario described, the nurse hears normal bronchovesicular breath sounds, which are moderate in intensity and resemble blowing as air moves through the larger airways during inspiration and expiration. Crackles (choice A) are typically heard in conditions like heart failure or pneumonia and are not present in this case. Rhonchi (choice B) are low-pitched, continuous sounds often associated with conditions like chronic bronchitis or bronchiectasis. Friction rub (choice C) is a grating sound usually heard in conditions like pleurisy or pericarditis, which is not the case here where normal breath sounds are heard.

4. The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?

• A. Roof of mouth, gums, and inside cheeks
• B. Chewing and inner tooth surfaces
• C. Outer tooth surfaces
• D. Tongue

Correct answer: C

Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.

5. To evaluate a client's understanding of self-administering insulin within the psychomotor domain of learning, what action should the instructor take?

• A. Have the client demonstrate the procedure.
• B. Explain the procedure again.
• C. Ask the client to describe the procedure.
• D. Observe the client watching a video on the procedure.

Correct answer: A

Rationale: Having the client demonstrate the procedure is the most appropriate action to evaluate understanding within the psychomotor domain of learning. This allows the instructor to assess the client's ability to perform the skill, which is a key aspect of this domain. Choice B, explaining the procedure again, focuses on the cognitive domain rather than the psychomotor domain. Choice C, asking the client to describe the procedure, pertains more to the verbal or cognitive domain of learning. Choice D, observing the client watching a video on the procedure, does not directly assess the client's ability to perform the skill in the psychomotor domain.

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