Nursing Elites

1. During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?

• A. Constipation
• B. Air-filled areas
• C. Presence of a tumor
• D. Presence of dense organs

Correct answer: B

Rationale: A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.

2. The client reports nausea and constipation. Which of the following would be the priority nursing action?

• A. Collect a stool sample
• B. Complete an abdominal assessment
• C. Administer an anti-nausea medication
• D. Notify the physician

Correct answer: B

Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (Choice A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (Choice C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (Choice D) should come after the assessment to provide a complete picture of the client's condition.

3. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?

• A. No, this temperature is within normal limits.
• B. No, this temperature is normally hyperthermic.
• C. Yes, this temperature is highly hyperthermic.
• D. Yes, this temperature is highly hypothermic.

Correct answer: A

Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.

4. A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

• A. A 2-month-old infant with a history of rolling off the bed and having a bulging fontanelle with crying
• B. A teenager who suffered singed facial hair while camping
• C. An elderly client with complaints of frequent liquid brown-colored stools
• D. A middle-aged client with intermittent pain behind the right scapula

Correct answer: B

Rationale: The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.

5. A home health nurse is preparing to visit her next client, whom she has never visited before. Which of the following actions indicates the nurse is upholding safety precautions?

• A. Send a text to the client to confirm the location of the house
• B. Leave her purse and valuables on the seat in the car and lock the doors
• C. Ask the client to keep an extra set of keys in case the car is locked
• D. Keep the car windows rolled up when in an unfamiliar environment

Correct answer: D

Rationale: The correct answer is to keep the car windows rolled up when in an unfamiliar environment. This action helps uphold safety precautions for the home health nurse. When visiting a new client in an unfamiliar area, it is essential to ensure personal safety. Keeping the car windows rolled up can prevent potential intruders or unwanted individuals from gaining access to the nurse while in the vehicle. This precaution is important for personal safety and security. Choice A, sending a text to the client to confirm the location of the house, is not directly related to the nurse's safety during the visit. While communication with the client is important, it does not directly address the nurse's safety. Choice B, leaving her purse and valuables on the seat in the car, poses a security risk. It is not advisable to leave valuables visible in the car, as it may attract thieves and compromise the nurse's safety. Choice C, asking the client to keep an extra set of keys, is more related to accessibility and convenience rather than the nurse's safety. While having an extra set of keys may be helpful, it does not directly address safety precautions for the nurse.

Similar Questions