Nursing Elites

1. The LPN needs to determine the client's respiratory rate. What is the best technique to do this?

• A. Tell the client you need to count their respiratory rate.
• B. Subtly watch the client from across the room when they are doing an activity.
• C. Ask the client to sit still for 30 seconds.
• D. Count respirations while pretending to check the client's pulse.

Correct answer: D

Rationale: The best technique to determine a client's respiratory rate is to count respirations while pretending to check the client's pulse. You should not inform the client that you are counting their respirations, as this might lead to a change in their breathing pattern. Pretending to check the pulse allows you to be close to the client without revealing that you are assessing their respiratory rate. Asking the client to sit still may not be as effective, as it may cause them to concentrate on their breathing. Watching from across the room may not provide an accurate assessment of respirations, as they might be difficult to observe.

2. Mr. H. is upset about being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:

• A. the right to examine and question the bill
• B. the right to reasonable response to requests
• C. the right to refuse treatment
• D. the right to confidentiality

Correct answer: D

Rationale: Confidentiality is the maintenance of privacy of information, which is not directly related to the issue Mr. H. is facing. The question indicates that Mr. H. is concerned about the cost of staying in the hospital, which pertains more to financial aspects and the right to examine and question the bill. The right to a reasonable response to requests and the right to refuse treatment are also crucial patient rights that Mr. H. may demand in his current situation. Therefore, the correct answer is the right to confidentiality, as it is not specifically relevant to the scenario presented.

3. A nurse assisting with data collection for a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding using which terminology?

• A. Anasarca
• B. Ecchymosis
• C. Unilateral edema
• D. Increased vascularity of the skin tissue

Correct answer: A

Rationale: The correct term for generalized edema over the entire body is 'Anasarca.' Anasarca is indicative of a systemic issue such as congestive heart failure or kidney failure. It does not refer to increased vascularity of the skin tissue. Ecchymosis is a bruise caused by capillary bleeding into the tissues, unrelated to generalized edema. Unilateral edema is swelling in a specific area of the body, not the generalized edema observed in anasarca.

4. A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that which aspect of eye function is normal?

• A. Near vision
• B. Central vision
• C. Peripheral vision
• D. Ocular movements

Correct answer: D

Rationale: The correct answer is 'Ocular movements.' Moving the eyes through the six cardinal fields of gaze evaluates the function of the eye muscles, such as the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Normal movement in these fields indicates proper ocular movements. Near vision is assessed using a handheld vision screener, central vision with a Snellen chart, and peripheral vision through the confrontation test. Therefore, the evaluation of ocular movements through the six cardinal fields of gaze specifically assesses this aspect of eye function. Choices A, B, and C are incorrect as they pertain to different aspects of vision function that are evaluated using distinct assessment methods, not through the six cardinal fields of gaze.

5. A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which part of the fetus?

• A. Back of the fetus
• B. Carotid artery in the neck of the fetus
• C. Brachial area of one extremity of the fetus
• D. Chest of the fetus

Correct answer: A

Rationale: The nurse would use the Leopold maneuvers to identify the position of the fetus and determine the location of the fetal back. The fetal heart rate (FHR) is most easily heard through the fetal back because it usually lies closest to the surface of the maternal abdomen. Auscultation of the FHR over the chest, carotid artery, or brachial area is not possible due to the fetal position within the maternal abdomen. Placing the fetoscope over the carotid artery or brachial area would not yield the fetal heart rate, and the chest area is not typically used for auscultating the FHR.

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