Nursing Elites

1. Assisting with data collection, a nurse notes tenderness while lightly palpating a client's right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?

• A. Liver
• B. Spleen
• C. Pancreas
• D. Appendix

Correct answer: D

Rationale: The correct answer is the Appendix. Tenderness in the right lower quadrant of the abdomen is a classic sign of appendicitis, which is inflammation of the appendix. The appendix is located in the right lower quadrant. The other choices are incorrect. The spleen is located on the posterolateral wall of the abdominal cavity under the diaphragm. The pancreas is located behind the stomach. The liver fills most of the right upper quadrant and extends to the left midclavicular line.

2. A client with dumping syndrome should..........................while a client with GERD should..........................

• A. Sit up 1 hour after meals; lie flat 30 minutes after meals
• B. Lie down 1 hour after eating; sit up at least 30 minutes after eating
• C. Sit up after meals; sit up after meals
• D. Lie down after meals; lie down after meals

Correct answer: D

Rationale: For a client with dumping syndrome, lying down 1 hour after eating helps reduce symptoms by slowing down the movement of food through the digestive tract, aiding in symptom management. This position assists in symptom management for dumping syndrome. Conversely, for a client with GERD, sitting up at least 30 minutes after eating can help prevent the backflow of stomach acid into the esophagus, reducing reflux symptoms. This upright position is beneficial for managing GERD. Choice A is incorrect because sitting up is recommended for GERD, not dumping syndrome. Choice C is incorrect as it suggests sitting up for both conditions, which is not appropriate. Choice D is incorrect as lying down after meals is not recommended for GERD; it can worsen symptoms by promoting acid reflux.

3. A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing seedy, mustard-yellow stools. The nurse provides the mother with which information?

• A. To monitor the infant for infection and, if a fever develops, to contact the pediatrician
• B. That the stools should be solid and pale yellow to light brown
• C. That this is normal for breastfed infants
• D. To decrease the number of feedings by two per day

Correct answer: C

Rationale: Breastfed infants pass very soft, seedy, mustard-yellow stools, which is considered normal. Formula-fed infants excrete stools that are more solid and pale yellow to light brown. It is essential for the mother to understand that seedy, mustard-yellow stools are expected in breastfed infants, indicating that there is no need for concern. Monitoring for infection as the first response without other symptoms can cause unnecessary anxiety. Decreasing the number of feedings without valid reasons can lead to inadequate nutrition for the newborn. Therefore, the correct advice for the nurse to provide in this scenario is that seedy, mustard-yellow stools are normal for breastfed infants, reassuring the mother and promoting proper understanding of newborn stool characteristics.

4. If Ms. Barrett's distance vision is 20/30, which of the following statements is true?

• A. The client can read from 20' what a person with normal vision can read at 30'.
• B. The client can read from 30' what a person with normal vision can read at 20'.
• C. The client can read the entire chart from 30'.
• D. The client can read the chart from 20' with the left eye and from 30' with the right eye.

Correct answer: A

Rationale: When Ms. Barrett's distance vision is measured as 20/30, it means that she can read from 20 feet away what a person with normal vision can read at 30 feet. The numerator (20) represents the distance in feet between the chart and the client, while the denominator (30) indicates the distance at which a normal eye can read the chart. In this case, Ms. Barrett's vision is slightly worse than normal, as she needs to be closer to the chart to read it clearly. Therefore, choice A is correct. Choices B, C, and D are incorrect: Choice B reverses the distances, Choice C assumes the client can read the entire chart from 30 feet, and Choice D introduces information not related to the 20/30 measurement.

5. A sexually active adolescent asks the school nurse about the use of latex condoms and the reduction of the risk of sexually transmitted infections (STIs). The nurse provides which information to the adolescent?

• A. Using a latex condom is a good method for reducing the risk of sexually transmitted infections (STIs).
• B. The only way to reduce the risk of transmission of STIs is abstinence.
• C. A spermicide needs to be used along with a condom to prevent transmission of STIs.
• D. Using a latex condom can reduce the risk of transmission of STIs.

Correct answer: D

Rationale: The correct answer is that using a condom during intercourse can reduce the risk of STI transmission. Abstinence is a way to prevent STIs, but not the only way. Using a spermicide along with a condom can help prevent pregnancy, not STIs. While condoms may fail to prevent pregnancy, they are effective in reducing the risk of STI transmission. Therefore, using a latex condom for pregnancy prevention is not directly related to preventing the transmission of STIs.

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