Nursing Elites

1. What are Korotkoff sounds?

• A. Sounds noted during diastole.
• B. The result of the vibration of blood against artery walls while blood pressure readings are being taken.
• C. Sounds only noted by skilled cardiologists.
• D. Distinct sounds which are classified into 6 phases.

Correct answer: B

Rationale: Korotkoff sounds are the sounds that occur when blood flows in an artery that has been temporarily compressed during a blood pressure measurement. These sounds result from the vibration of blood against the artery walls as the pressure cuff is released. There are five distinct phases of Korotkoff sounds, which healthcare providers are trained to identify during blood pressure assessment. The correct answer, choice B, accurately describes the nature of Korotkoff sounds and how they are generated. Choices A, C, and D are incorrect because Korotkoff sounds are not specific to diastole, not limited to skilled cardiologists, and categorized into five phases, not six.

2. A client is being instructed on how to use crutches. Which of the following information should be included in the teaching?

• A. Place the majority of body weight on the axilla.
• B. Dry crutch tips with a paper towel if they become wet.
• C. Use the crutches for support to lift both feet simultaneously when ascending stairs.
• D. Both B and C.

Correct answer: B

Rationale: When instructing a client on how to use crutches for ambulation, it is important to emphasize keeping the crutch tips dry to prevent slipping while bearing weight on them. Moisture on the crutch tips can lead to accidents. Therefore, the correct answer is to dry the crutch tips with a paper towel if they become wet. Choice A, placing the majority of body weight on the axilla, is incorrect as the weight should be borne through the hands, not the axilla, to avoid nerve damage. Choice C, using the crutches to lift both feet simultaneously when ascending stairs, is incorrect as the client should ascend stairs by placing weight on the unaffected leg first, followed by the crutches and then the affected leg. This method provides stability and safety during stair climbing.

3. Which of the following questions is considered open-ended?

• A. What time did you last take your medications?
• B. Are you feeling okay right now?
• C. Please describe your symptoms.
• D. What day are you available for a follow-up appointment?

Correct answer: C

Rationale: The correct answer is 'Please describe your symptoms.' This question is considered open-ended because it encourages the respondent to provide a detailed and descriptive answer, fostering a more elaborate response. Open-ended questions are designed to prompt thoughtful and detailed responses. Choice A is a closed-ended question since it seeks a specific time for the medication intake. Choice B is also closed-ended as it can be answered with a simple 'yes' or 'no,' limiting the response. Choice D is closed-ended as it requests a specific day for the follow-up appointment, restricting the range of possible responses.

4. During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?

• A. Fingertips
• B. Dorsal surface of the hand
• C. Ulnar portion of the hand
• D. Palmar surface of the hand

Correct answer: B

Rationale: The correct answer is the dorsal surface of the hand. The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination and not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not as effective for assessing skin temperature as the dorsal surface because they have thicker skin layers.

5. For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

• A. Assessing the patient for jaundice
• B. Providing oral hygiene after a meal
• C. Palpating the abdomen for distention
• D. Assisting the patient to choose the diet

Correct answer: B

Rationale: Providing oral hygiene after a meal is an appropriate task to delegate to unlicensed assistive personnel (UAP) as it falls within their scope of practice. UAP can assist with basic personal care activities like oral hygiene. Assessing the patient for jaundice and palpating the abdomen for distention involve making clinical assessments that require a higher level of education and training, typically performed by licensed practical/vocational nurses (LPNs/LVNs) or registered nurses (RNs). Assisting the patient to choose the diet also requires specialized knowledge and would be more appropriate for a nurse to address, considering the complexity of dietary requirements in cirrhosis.

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