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. When should discharge planning for a patient admitted to the neurological unit with a diagnosis of stroke begin?

• A. At the time of admission
• B. The day before the patient is to be discharged
• C. When outpatient therapy is no longer needed
• D. As soon as the patient's discharge destination is known

Correct answer: A

Rationale: Discharge planning for a patient admitted to the neurological unit with a stroke diagnosis should begin at the time of admission. Initiating discharge planning early allows for a comprehensive assessment of the patient's needs, enables better coordination of care, and ensures a smooth transition from the hospital to the next level of care. Option B is incorrect because waiting until the day before discharge does not provide enough time for adequate planning. Option C is incorrect because waiting until outpatient therapy is no longer needed delays the planning process. Option D is incorrect because waiting until the discharge destination is known may result in rushed planning and inadequate preparation for the patient's needs.

3. A client who is postoperative following abdominal surgery has an eviscerated wound. What should the nurse do first?

• A. Cover the incision with a moist sterile dressing.
• B. Notify the surgeon immediately.
• C. Assess the client's vital signs.
• D. Place the client in a supine position with knees bent.

Correct answer: A

Rationale: The initial action the nurse should take after discovering a client's eviscerated wound is to cover the incision with a moist sterile dressing. This step is crucial to protect the exposed tissue, prevent infection, and create a conducive environment for healing. While notifying the surgeon is important, addressing the wound immediately takes precedence. Assessing vital signs is essential but should follow the immediate intervention of covering the wound. Placing the client in a supine position with knees bent is not the priority in managing an eviscerated wound; the first step is to cover the wound to protect the exposed tissue.

4. A healthcare professional is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the healthcare professional question?

• A. Oral psyllium (Metamucil)
• B. Oral potassium supplement
• C. Parenteral half normal saline
• D. Parenteral albumin (Albuminar)

Correct answer: D

Rationale: The correct answer is D, Parenteral albumin (Albuminar). Parenteral albumin is not typically indicated for dehydration resulting from diarrhea. In this case, fluid replacement therapy with intravenous fluids such as parenteral half normal saline would be more appropriate. Oral psyllium and oral potassium supplement are not the primary interventions for managing dehydration due to watery diarrhea. Oral psyllium is a fiber supplement used for constipation rather than diarrhea. Oral potassium supplements may be necessary if potassium levels are low due to dehydration, but the priority is fluid replacement. Therefore, choices A and B are less relevant in this scenario.

5. A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding 'stronger pain medications.' What initial action is most important for the LPN/LVN to take?

• A. Ask about any past history of drug abuse or addiction.
• B. Measure the pulse volume and capillary refill distal to the infiltration.
• C. Compress the infiltrated tissue to measure the degree of edema.
• D. Evaluate the extent of ecchymosis over the forearm area.

Correct answer: B

Rationale: The most important initial action for the LPN/LVN to take in this situation is to measure the pulse volume and capillary refill distal to the infiltration. This assessment helps evaluate the severity of the infiltration and the circulation in the affected arm. Asking about past history of drug abuse or addiction (Choice A) is not the priority when addressing acute arm pain and infiltration. Compressing the infiltrated tissue (Choice C) may exacerbate the pain and is not recommended as the first step. Evaluating the extent of ecchymosis (Choice D) is not as critical as assessing the circulation in the affected arm, which is better addressed by measuring pulse volume and capillary refill.

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