Nursing Elites

1. When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?

• A. nausea and vomiting
• B. itching
• C. urinary retention
• D. somnolence

Correct answer: B

Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. While urinary retention is a side effect of postpartum epidural morphine, it is not typically assessed within the first 3 hours. Somnolence is a rare side effect and not commonly observed within the first 3 hours. Therefore, itching is the most likely side effect to be observed within the initial 3 hours after administering postpartum epidural morphine.

2. When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?

• A. It is less painful for the client.
• B. Palpation and percussion can increase peristalsis.
• C. It identifies any potential areas of abdominal tenderness.
• D. It gives the client more time to become comfortable with the examiner.

Correct answer: B

Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. This sequence helps prevent false interpretations of bowel sounds due to increased peristalsis caused by palpation and percussion. Options A, C, and D provide incorrect reasons for auscultating the abdomen before palpating and percussing it.

3. Around what age do children typically start to develop 'stranger anxiety'?

• A. 9 months
• B. 6 months
• C. 3 months
• D. 12 months

Correct answer: B

Rationale: The correct answer is '6 months.' At around this age, children typically start to develop 'stranger anxiety' as they become more aware of unfamiliar faces and may start showing signs of distress or anxiety around strangers. At 3 months, infants are still very young and unlikely to display stranger anxiety. While by 9 or 12 months, children have usually already developed some level of stranger anxiety, it typically starts around 6 months, making it the most appropriate answer in this context.

4. The LPN on shift notices a client coming into the clinic with bruises on his arm. The client seems very afraid and doesn't speak much, which concerns the nurse because these are signs of physical abuse. The nurse should ____.

• A. use therapeutic communication to talk to the client and offer support while reporting the findings to the appropriate authorities based on the state requirements and protocols
• B. report the findings to the appropriate authorities based on the state requirements and protocols
• C. ignore the bruises, as this is not why the client is being treated and is not appropriate for the nurse to address
• D. report the suspected abuse to another nurse and collaborate on how to handle it

Correct answer: B

Rationale: In cases of suspected abuse, healthcare providers have a legal and ethical obligation to report such incidents to the relevant authorities. This not only ensures the safety and well-being of the client but also helps in preventing further harm. Option A is incorrect as attempting to gather evidence of abuse may interfere with the official investigation and is not the nurse's role. Offering support is crucial, but the priority is to report the findings to the appropriate authorities. Option C is incorrect as ignoring signs of abuse goes against the duty of a healthcare provider to protect their clients. Option D is incorrect as reporting suspected abuse to other nurses without involving the appropriate authorities may delay necessary actions and intervention.

5. How should a nurse listen to the breath sounds of a client?

• A. Ask the client to lie prone.
• B. Ask the client to breathe in and out through the nose.
• C. Hold the bell of the stethoscope lightly against the chest.
• D. Listen for at least one full respiration in each location on the chest.

Correct answer: D

Rationale: To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment. Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.

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