Nursing Elites

1. Which desired outcome written by the nurse is correctly written and measurable?

• A. Client will have a normal bowel pattern by April 2
• B. The client will lose 4 lbs. within the next 2 weeks
• C. The nurse will provide skin care at least 3 times each day
• D. The client will breathe better after resting for 10 minutes

Correct answer: B

Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Option B is correctly written and measurable as it includes all the required elements: subject (client), action verb (lose), conditions (within the next 2 weeks), and the level at which the behavior should occur (4 lbs.). Option A lacks the conditions and a specific level, making it not measurable. Option C is a nursing intervention rather than a client goal. Option D does not provide a specific level at which the client should perform the desired behavior, making it not measurable as well.

2. The nurse is assessing an 80-year-old male patient. Which assessment finding would be considered normal?

• A. Decrease in body weight from his younger years
• B. Decrease in deposits of fat in the cheeks and forearms
• C. Presence of kyphosis and flexion in bilateral knees and hips
• D. Change in overall body proportion, including a longer trunk and shorter extremities

Correct answer: C

Rationale: In an 80-year-old male patient, the presence of kyphosis (rounded upper back) and flexion in bilateral knees and hips are considered normal age-related changes. These postural changes are commonly seen in older adults due to structural changes in the spine and joints. Option A is incorrect as aging individuals typically experience a decrease in body weight, not an increase. Option B is also incorrect as there is usually a decrease in subcutaneous fat from the face and periphery, rather than an increase in fat deposits in specific areas. Option D is incorrect because the change in overall body proportion with aging usually involves a shorter trunk and relatively longer extremities, not the other way around. This is because long bones do not shorten with age, leading to this characteristic change in body proportions.

3. After performing the appropriate client assessment, which of the following inferences would the nurse make?

• A. Client is hypotensive
• B. Respiratory rate of 20 breaths per minute
• C. Oxygen saturation of 95%
• D. Client relays anxiety about blood work

Correct answer: A

Rationale: An inference is the nurse's judgment or interpretation of cues gathered during an assessment. In this scenario, identifying a client as hypotensive would be an inference based on blood pressure readings that indicate lower than normal values. Respiratory rate and oxygen saturation levels (choices B and C) are important cues that provide additional data but do not directly point to a specific conclusion like hypotension. The client expressing anxiety about blood work (choice D) is relevant information but relates more to their emotional state rather than a physiological assessment finding.

4. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments would be used to assess this murmur?

• A. Electrocardiogram
• B. Bell of the stethoscope
• C. Diaphragm of the stethoscope
• D. Palpation with the nurse's palm of the hand

Correct answer: B

Rationale: The correct instrument to assess a murmur while auscultating heart sounds is the bell of the stethoscope. An electrocardiogram is used to measure the heart's electrical activity, not to assess murmurs. Palpation with the nurse's palm of the hand is a method to assess pulses or textures, not heart murmurs. The diaphragm of the stethoscope is typically used for high-pitched sounds like breath, bowel, and normal heart sounds, whereas the bell is more suitable for soft, low-pitched sounds such as murmurs or extra heart sounds.

5. When examining an infant, which area should the nurse examine first?

• A. Ear
• B. Nose
• C. Throat
• D. Abdomen

Correct answer: D

Rationale: When examining an infant, the nurse should start by examining the least-distressing areas first before moving on to more invasive areas. The abdomen is typically the least distressing area to examine, so it should be assessed first. Examining the eye, ear, nose, and throat are considered more invasive and should be saved for last. Therefore, the correct choice is to examine the abdomen first to ensure a comfortable and less distressing examination process for the infant. Choices A, B, and C (Ear, Nose, Throat) are more invasive areas and should be examined after the abdomen.

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