Nursing Elites

1. During the physical assessment, which finding should the nurse recognize as a normal finding?

• A. Regular pulsation at the epigastric area when the client is supine.
• B. A loud, harsh murmur at the second right intercostal space.
• C. Dullness over the lung fields.
• D. Increased tactile fremitus.

Correct answer: A

Rationale: The regular pulsation at the epigastric area when the client is supine is a normal finding. This phenomenon is caused by the regular and recurrent expansion and contraction of an artery due to waves of pressure caused by the ejection of blood from the left ventricle. Choices B, C, and D describe abnormal findings during a physical assessment. A loud, harsh murmur at the second right intercostal space indicates an abnormal heart sound, dullness over the lung fields may suggest consolidation or fluid in the lungs, and increased tactile fremitus can be a sign of lung consolidation or pathology.

2. The nurse must delegate some aspects of a homebound client's care to a home health aide. Which intervention should the nurse delegate to the home health aide?

• A. evaluating a pressure sore
• B. applying a prosthetic device
• C. performing a sterile dressing change
• D. assessing the client's need for an elevated toilet seat

Correct answer: B

Rationale: The correct answer is B: applying a prosthetic device. Home health aides are trained and authorized to assist with the application and management of prosthetic devices for clients. Evaluating a pressure sore (choice A) requires clinical assessment and judgment typically performed by a licensed healthcare provider such as a nurse. Performing a sterile dressing change (choice C) involves aseptic technique and wound care skills that are usually performed by licensed healthcare professionals. Assessing the client's need for an elevated toilet seat (choice D) involves a level of assessment and decision-making that is beyond the scope of practice for a home health aide.

3. A public health nurse is evaluating a program designed to reduce the incidence of diabetes in the community. Which outcome indicates that the program is successful?

• A. increased participation in diabetes education sessions
• B. higher rates of blood glucose monitoring
• C. reduced incidence of diabetes-related complications
• D. greater knowledge of diabetes prevention methods

Correct answer: C

Rationale: The correct answer is C: 'reduced incidence of diabetes-related complications.' This outcome indicates that the program is successful because it shows that individuals are effectively managing their condition, leading to fewer complications. Increased participation in education sessions (choice A) and higher rates of blood glucose monitoring (choice B) are important but are more process indicators rather than direct outcomes of improved health. Greater knowledge of prevention methods (choice D) is beneficial but may not directly reflect a reduction in diabetes incidence or complications.

4. The healthcare provider is preparing to administer intravenous immune globulin (IVIG) to a client with Guillain-Barre syndrome. Which assessment is most important before initiating the infusion?

• A. Lung sounds and respiratory status.
• B. Skin integrity and color.
• C. Neurological status and level of consciousness.
• D. Cardiac rate and rhythm.

Correct answer: D

Rationale: The correct answer is D, "Cardiac rate and rhythm." Monitoring cardiac rate and rhythm is crucial before initiating IVIG because bradycardia is a common side effect associated with this therapy. Assessing lung sounds and respiratory status (Choice A) is important, but cardiac monitoring takes precedence due to the risk of bradycardia. Skin integrity and color (Choice B) are important assessments, but they are not directly related to potential complications of IVIG infusion. Neurological status and level of consciousness (Choice C) are also vital assessments, but monitoring cardiac function is more pertinent in this scenario.

5. During a repeat home visit to see an 84-year-old widow, the nurse discovers that the client is unkempt, smells of stale urine, and does not recognize her neighbors or the nurse. What action should the nurse take?

• A. Call the pharmacy to determine what medications she is taking
• B. Seek the family's assistance in taking care of the client
• C. Complete a physical and mental exam on the client
• D. Call the adult protective services to obtain emergency nursing home placement

Correct answer: C

Rationale: In this scenario, the nurse should prioritize completing a physical and mental exam on the client. This action is crucial to assess the client's health status comprehensively and identify any underlying issues contributing to her unkempt appearance, odor of stale urine, and confusion. Calling the pharmacy to determine medications (Choice A) may be important but is not the immediate priority. Seeking family assistance (Choice B) can be helpful, but the client's condition requires a thorough assessment first. While adult protective services (Choice D) may be necessary in the future, the immediate action should be to assess the client's physical and mental health status.

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