Nursing Elites

1. What do high-pitched gurgles heard over the right lower quadrant indicate?

• A. Increased bowel motility
• B. Decreased bowel motility
• C. Normal bowel sounds
• D. Abdominal cramping

Correct answer: C

Rationale: High-pitched gurgles heard over the right lower quadrant indicate normal bowel sounds. Bowel sounds can vary in pitch, and high-pitched gurgles are considered normal and indicate the presence of active peristalsis in the intestines.

2. A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
• B. ''I will lie on my back with my knees bent.''
• C. ''I will rest my hand over my abdomen to create resistance.''
• D. ''I will take in a deep breath and hold it before exhaling.''

Correct answer: D

Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.

3. During a shift change, a nurse is receiving a report for an adult female client who is postoperative. Which of the following client information should the nurse report?

• A. High platelets
• B. Hypertension
• C. Lower platelets
• D. High temperatures

Correct answer: C

Rationale: Lower platelets can indicate a potential risk of bleeding in a postoperative client. Thrombocytopenia, or low platelet count, can lead to increased bleeding tendencies and should be promptly reported to the healthcare team for appropriate management. Monitoring platelet levels is crucial in postoperative care to prevent complications related to inadequate clotting ability.

4. When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.

5. Which of the following is not a cause of tachycardia?

• A. Fever
• B. Exercise
• C. Sympathetic nervous system stimulation
• D. Parasympathetic nervous system stimulation

Correct answer: D

Rationale: Tachycardia is an increased heart rate, and it can be caused by various factors such as fever, exercise, and sympathetic nervous system stimulation, all of which tend to increase heart rate. However, parasympathetic nervous system stimulation typically slows the heart rate, making it the exception among the choices provided. Thus, parasympathetic nervous system stimulation is not a cause of tachycardia.

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