Nursing Elites

1. During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?

• A. Fat
• B. Fluid
• C. Flatus
• D. Hernias

Correct answer: D

Rationale: The correct answer is 'Hernias.' Abdominal distention with a midline protrusion, taut skin, and no involvement of the flanks is characteristic of hernias. Hernias are caused by a weakness in the abdominal wall, allowing organs or tissues to protrude through. Fluid accumulation (ascites) typically presents with a more generalized distention, while fat accumulation may cause more diffuse distension rather than a focal midline protrusion. Flatus, or gas, would not typically present with a visible midline protrusion and taut skin like hernias.

2. The nurse is caring for a patient who has experienced a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive range of motion (ROM) will be initiated. When should the nurse begin this therapy?

• A. After the acute phase of the disease has passed.
• B. As soon as the ability to move is lost.
• C. Once the patient enters the rehab unit.
• D. When the patient requests it.

Correct answer: B

Rationale: Passive ROM exercises should begin as soon as the patient loses the ability to move the extremity or joint. Initiating passive ROM early helps prevent contractures and maintain joint function. Choice A is incorrect because delaying passive ROM until after the acute phase may lead to irreversible contractures. Choice C is not the best option as waiting until the patient enters the rehab unit delays crucial preventive measures. Choice D is incorrect as passive ROM should not be based on patient requests but on clinical indications and best practices.

3. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar. Which of the following actions should the nurse take?

• A. Consult the medication reference book available on the unit.
• B. Administer the medication as ordered.
• C. Ask a colleague for information about the medication.
• D. Contact the provider to clarify the medication.

Correct answer: A

Rationale: When encountering an unfamiliar medication, the safest action for a nurse is to consult the medication reference book available on the unit. This resource provides accurate and detailed information about medications, including indications, dosages, side effects, and nursing considerations. Administering a medication without understanding it (choice B) can lead to medication errors and harm to the client. Asking a colleague for information (choice C) may not always provide accurate or up-to-date information. Contacting the provider (choice D) should be reserved for situations where immediate clarification is needed, but consulting the reference book is the initial step to gain knowledge and ensure safe medication administration.

4. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further?

• A. “I have my own apartment now, but it’s not easy living away from my guardians.”
• B. “It’s been so stressful for me to even think about having my own family.”
• C. “I don’t even know who I am yet, and now I’m supposed to know what to do.”
• D. “My partner is pregnant, and I don’t think I have what it takes to be a good parent.”

Correct answer: D

Rationale: The statement about feeling unprepared to be a good parent indicates a significant concern that may need further assessment and support. This statement raises issues regarding the individual's readiness for parenthood and potential impact on the partner and the unborn child. Choices A, B, and C, while important, do not present immediate concerns regarding the well-being of another individual and do not raise potential risks that could have a direct impact on others.

5. When reviewing car seat use with the parents of a 1-month-old infant, which of the following instructions should the nurse include?

• A. Use a car seat that has a three-point harness system.
• B. Position the car seat so that the infant is rear-facing.
• C. Secure the car seat in the front passenger seat of the vehicle.
• D. Convert to a booster seat after 12 months.

Correct answer: B

Rationale: The correct instruction for car seat use with a 1-month-old infant is to position the car seat so that the infant is rear-facing. This orientation provides the safest option for infants as it supports their head, neck, and spine. While using a car seat with a three-point harness system is appropriate for infants, placing the car seat in the front passenger seat is not recommended due to the presence of airbags, which can pose a risk to the infant in the event of deployment. Additionally, transitioning to a booster seat is not suitable at 12 months; infants should remain in rear-facing car seats until they outgrow the seat's height or weight limits, typically around 2 years of age.

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