Nursing Elites

1. What are the correct steps used for abdominal assessment?

• A. Inspection, auscultation, percussion, palpation
• B. Palpation, inspection, auscultation, percussion
• C. Percussion, palpation, inspection, auscultation
• D. Auscultation, palpation, percussion, inspection

Correct answer: A

Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation follows to listen for bowel sounds and vascular sounds. Percussion helps to assess the density of underlying structures and detect any abnormal masses. Palpation is performed last to assess tenderness, organ size, and detect any masses. Choices B, C, and D have the steps in the incorrect order, making them the wrong choices.

2. A client is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

• A. Hemolytic
• B. Allergic
• C. Febrile
• D. Transfusion-related acute lung injury (TRALI)

Correct answer: A

Rationale: The correct answer is A: Hemolytic. Hemolytic reactions can lead to flank pain and hemoglobinuria, as the body breaks down the transfused red blood cells. In hemolytic reactions, the immune system attacks and destroys the transfused red blood cells, causing the release of hemoglobin into the bloodstream and urine. This results in reddish-brown urine, indicating hemoglobinuria. Allergic reactions typically present with symptoms like itching, hives, or rash. Febrile reactions are characterized by fever, chills, and rigors. TRALI is a rare but serious transfusion reaction that manifests as acute respiratory distress following a transfusion, not flank pain and hemoglobinuria.

3. When preparing to apply dressing to a stage 2 pressure injury, which type of dressing should the nurse use?

• A. Hydrocolloid
• B. Gauze
• C. Transparent film
• D. Alginate

Correct answer: A

Rationale: The correct answer is A: Hydrocolloid. Hydrocolloid dressings are recommended for stage 2 pressure injuries as they help maintain a moist wound environment, which supports the healing process. Gauze (choice B) is not ideal for stage 2 pressure injuries as it can stick to the wound bed and disrupt the healing process. Transparent film dressings (choice C) are more suitable for superficial wounds or as a secondary dressing. Alginate dressings (choice D) are typically used for wounds with heavy exudate, which is not typically seen in stage 2 pressure injuries.

4. When caring for a client prescribed a blood transfusion that parents refuse due to religious beliefs, what should the nurse do?

• A. Examine personal values about the issue.
• B. Proceed with the transfusion if medically necessary.
• C. Refer the issue to the ethics committee.
• D. Administer the blood transfusion without informing the parents.

Correct answer: A

Rationale: When faced with a situation where parents refuse a prescribed treatment due to religious beliefs, the nurse should first examine personal values, understand the client's or family’s beliefs, and respect their rights. Proceeding with the transfusion against the parents' wishes without exploring alternatives or understanding their perspective would violate the principle of respect for autonomy and could damage the therapeutic relationship. Referring the issue to the ethics committee should be considered if a resolution cannot be reached through open communication and negotiation with the family.

5. During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

• A. Mongolian spots are a normal finding in dark-skinned infants.
• B. Port wine stains are typically associated with other malformations.
• C. Telangiectatic nevi are normal and will disappear as the baby grows.
• D. The child is too young for surgical removal of these at this time.

Correct answer: C

Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.

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