Nursing Elites

1. A nurse receives a report about a client receiving IV fluids infusing at 125 mL/hr but notes they have only received 80 mL over the last 2 hours. What should the nurse do first?

• A. Check IV tubing for obstruction
• B. Increase the flow rate
• C. Change the IV site
• D. Notify the physician

Correct answer: A

Rationale: The correct first action for the nurse to take is to check the IV tubing for obstruction. This step is crucial in ensuring that the IV fluids are flowing properly and that there are no blockages preventing the correct infusion rate. Increasing the flow rate (Choice B) without confirming the tubing's status could lead to potential complications if there is indeed an obstruction. Changing the IV site (Choice C) is not the priority in this situation unless there are specific clinical indications. Notifying the physician (Choice D) can be done after checking the tubing for obstruction, as the physician may need to be informed depending on the findings.

2. During a Weber test, what is an appropriate action for the nurse to take?

• A. Deliver a series of high-pitched sounds at random intervals.
• B. Place an activated tuning fork in the middle of the client's forehead.
• C. Hold an activated tuning fork against the client's mastoid process.
• D. Whisper a series of words softly into one ear.

Correct answer: B

Rationale: During a Weber test, the nurse should place an activated tuning fork in the middle of the client's forehead. This test is used to assess for lateralization of sound in a client with possible hearing issues. Choice A is incorrect because the Weber test does not involve delivering high-pitched sounds at random intervals. Choice C is incorrect as it describes the Rinne test, not the Weber test. Choice D is incorrect as whispering words into one ear is not part of the Weber test procedure.

3. When teaching the guardian of a 12-year-old male client about manifestations of puberty, which of the following physical changes typically occurs first?

• A. Appearance of downy hair on the upper lip
• B. Hair growth in the axillae
• C. Enlargement of the testes and scrotum
• D. Deepening of the voice

Correct answer: C

Rationale: During puberty in males, the first physical change that typically occurs is the enlargement of the testes and scrotum. This change is due to increased production of testosterone, which stimulates growth and development of the genital organs. The appearance of downy hair on the upper lip (Choice A) and hair growth in the axillae (Choice B) usually follow the enlargement of the testes and scrotum. Deepening of the voice (Choice D) is a later stage change that occurs during puberty as the larynx (voice box) grows and the vocal cords lengthen and thicken.

4. A client reports increased pain following physical therapy. Which of the following questions should the nurse ask to assess the quality of the pain?

• A. Is the pain sharp or dull?
• B. Does the pain feel like burning or aching?
• C. Is the pain constant or intermittent?
• D. Does the pain feel like throbbing or stabbing?

Correct answer: A

Rationale: When assessing pain quality, asking if the pain is sharp or dull helps determine the nature of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate a chronic issue. Choices B, C, and D are incorrect as they do not directly address the quality of the pain in terms of sharpness or dullness.

5. A client has left lower atelectasis. In which of the following positions should the nurse place the client for postural drainage?

• A. Supine and low Fowler's position
• B. Right lateral in Trendelenburg position
• C. Side lying with the right side of the chest elevated
• D. Prone with pillows under the extremities

Correct answer: B

Rationale: Postural drainage is a technique used to help remove secretions from specific lung segments. For left lower atelectasis, placing the client in the right lateral Trendelenburg position is most effective. This position helps target the affected area, using gravity to assist in drainage. Placing the client in a supine or low Fowler's position (Choice A) may not effectively target the affected area. Side lying with the right side of the chest elevated (Choice C) would not utilize gravity for optimal drainage. Placing the client prone with pillows under the extremities (Choice D) is not ideal for postural drainage of the left lower lobe.

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