Nursing Elites

1. During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?

• A. Ask the patient how he or she is feeling.
• B. Document the findings in the patient's record.
• C. Wait 10 minutes and auscultate the sound again.
• D. Ask another nurse to double-check the finding.

Correct answer: D

Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.

2. Which of the following puts the layers of skin in the correct order from right to left?

• A. Dermis, epidermis, hypodermis
• B. Hypodermis, epidermis, dermis
• C. Epidermis, dermis, hypodermis
• D. None of the above

Correct answer: C

Rationale: The correct order of the layers of skin from outermost to innermost is the epidermis, dermis, and then the hypodermis. The epidermis is the outermost layer of the skin, followed by the dermis, which is the middle layer containing connective tissue, hair follicles, and sweat glands. The hypodermis, also known as the subcutaneous tissue, lies beneath the dermis and consists of fat and connective tissue. Choice A is incorrect as it lists the layers in the reverse order. Choice B is incorrect as it reverses the order of the layers. Choice D is incorrect as there is a correct answer among the choices.

3. A healthcare professional is asked to draw blood in the antecubital (AC) space. Which of the following veins are found in the AC?

• A. Cephalic
• B. Median cubital
• C. Basilic
• D. All of the above

Correct answer: D

Rationale: The correct answer is 'All of the above.' All three of these veins - the cephalic, median cubital, and basilic veins - are located in the antecubital space, which is the area in front of the elbow on the arm. The cephalic vein runs along the outer side of the arm, the basilic vein runs along the inner side of the arm, and the median cubital vein is a connecting vein between the cephalic and basilic veins. Therefore, all three veins can be accessed when drawing blood from the antecubital space. Choices A, B, and C are incorrect because each of these veins individually can be found in the antecubital space.

4. 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.

5. Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?

• A. Keep all of the side rails up
• B. Review prescribed medications
• C. Complete the "get up and go"? test
• D. Place the bed in the lowest position

Correct answer: D

Rationale: The highest priority nursing intervention for a client at risk for falls in a hospital setting is to place the bed in the lowest position. This action ensures that the client falls the shortest distance, reducing the risk of injury. Keeping all side rails up (Option A) may lead to a fall with injury, as the client might attempt to get over the rail and fall from a higher distance. Reviewing prescribed medications (Option B) is important as certain medications can increase the risk of falling, but it is not the best answer as it is not applicable to all clients. Completing the "get up and go"? test (Option C) can help assess a client's risk for falling but does not directly prevent injury.

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