Nursing Elites

1. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

• A. Notify the healthcare provider
• B. Document that the pericarditis has resolved
• C. Ask the client to lean forward and listen again
• D. Prepare to insert a unilateral chest tube

Correct answer: C

Rationale: The correct action for the nurse to take when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. This position brings the heart closer to the chest wall, making it easier to detect a friction rub if present. Notifying the healthcare provider is not necessary at this point as it may just be a matter of positioning for better auscultation. Documenting that the pericarditis has resolved is premature without proper assessment. Preparing to insert a unilateral chest tube is not indicated based on the absence of a friction rub.

2. The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. What is the nurse’s priority intervention?

• A. Escort the client to the physical therapy department
• B. Medicate the client 30 minutes before going to the whirlpool
• C. Obtain the sterile dressing supplies for the client
• D. Assist the client to the bathroom prior to the treatment

Correct answer: B

Rationale: The correct answer is B. Pain management is essential before the procedure to ensure the client’s comfort and cooperation during the dressing change. Escorting the client to the physical therapy department (Choice A) is not the priority at this point. Obtaining sterile dressing supplies (Choice C) is important but not the priority before addressing pain management. Assisting the client to the bathroom (Choice D) is not the priority intervention for a dressing change in the whirlpool.

3. The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:

• A. Astride one of her hips
• B. Strapped in an infant seat
• C. Wrapped tightly in a blanket
• D. Under the arm using a football hold

Correct answer: A

Rationale: Carrying the infant astride one of her hips helps keep the legs apart and can help reduce muscle tightness. This position allows for better support and alignment, preventing further muscle contractures. Strapping the infant in an infant seat, wrapping tightly in a blanket, or using the football hold under the arm would not provide the same benefits and may even exacerbate muscle tightness in a child with cerebral palsy.

4. Management experience prepares the practical nurse to be a Clinical NCO or a Senior Clinical NCO. These positions are normally held by which of the following?

• A. Army Nurse Corps officer
• B. First Sergeant
• C. E6, E7, or E8
• D. E3, E4, or E5

Correct answer: C

Rationale: Corrected Rationale: Clinical NCO or Senior Clinical NCO positions are typically held by personnel ranked E6, E7, or E8 in the military structure. These individuals have the necessary experience and leadership skills to fulfill the responsibilities associated with these roles. Choices A, B, and D are incorrect because these positions are not specifically designated for Army Nurse Corps officers, First Sergeants, E3, E4, or E5 personnel in the military hierarchy.

5. During a physical assessment of a newborn, what finding should the nurse prioritize reporting?

• A. Head circumference of 40 cm
• B. Chest circumference of 32 cm
• C. Acrocyanosis and edema of the scalp
• D. Heart rate of 160 bpm and respirations of 40/min

Correct answer: A

Rationale: The correct answer is A because a head circumference of 40 cm is unusually large for a newborn, which may indicate hydrocephalus or other abnormalities. Reporting this finding is crucial for further evaluation and intervention. Choices B, C, and D are not as concerning during a newborn physical assessment. A chest circumference of 32 cm is within the normal range for a newborn. Acrocyanosis and edema of the scalp are common findings in newborns and usually resolve without intervention. While a heart rate of 160 bpm and respirations of 40/min should be monitored, they are not as critical as an unusually large head circumference.

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