Nursing Elites

1. What is the correct sequence for assessing the abdomen?

• A. Tympanic percussion, measurement of abdominal girth, and inspection
• B. Assessment for distention, tenderness, and discoloration around the umbilicus
• C. Percussion, palpation, and auscultation
• D. Auscultation, percussion, and palpation

Correct answer: D

Rationale: The correct sequence for assessing the abdomen is auscultation, percussion, and palpation. Auscultation allows the healthcare provider to listen for bowel sounds, followed by percussion to assess for areas of tenderness or abnormal distention, and finally palpation to feel for masses or organ enlargement. This sequence ensures a systematic and thorough assessment of the abdomen.

2. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

• A. Hemoglobinuria
• B. Chest pain
• C. Urticaria
• D. Distended neck veins

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.

3. The healthcare provider orders the administration of an ampicillin capsule TID p.o. The healthcare provider should give the medication...

• A. Three times a day orally
• B. Three times a day after meals
• C. Two times a day by mouth
• D. Two times a day before meals

Correct answer: A

Rationale: In medical abbreviations, 'TID' stands for 'ter in die,' which means three times a day, and 'p.o.' stands for 'per os,' which means orally. Therefore, the correct administration schedule for the ampicillin capsule is three times a day orally. Choices B, C, and D are incorrect because they do not align with the prescribed frequency or route of administration specified in the order.

4. Which of the following parameters should be checked when assessing respirations?

• A. Rate
• B. Rhythm
• C. Symmetry
• D. All of the above

Correct answer: D

Rationale: When assessing respirations, it is essential to evaluate the rate at which breaths are taken, the rhythm of breathing patterns, and the symmetry of chest expansion. Each of these parameters provides valuable information about a person's respiratory status. Therefore, it is important to assess all of the listed parameters to have a comprehensive understanding of the individual's respiratory function.

5. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?

• A. Arrange for an ethics committee meeting to address the family's concerns.
• B. Support the family's decision and initiate life-sustaining measures.
• C. Complete an incident report.
• D. Encourage the family to contact an attorney.

Correct answer: A

Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.

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