Nursing Elites

1. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client?

• A. Loosen pressure dressings on wounds
• B. Use assistance to lift a client in bed
• C. Check temperature of water used in a sponge bath
• D. Position the client in a prone position

Correct answer: C

Rationale: To reduce environmental stimuli that may cause discomfort for a client, nurses can implement various interventions. Checking the temperature of the water used in a sponge bath is crucial to prevent burns from water that is too hot or discomfort from water that is too cold. This intervention addresses a common source of discomfort for clients during personal care. Loosening pressure dressings on wounds, although important for wound care, does not directly address environmental stimuli. Using assistance to lift a client in bed is about proper positioning and preventing injury rather than reducing environmental stimuli. Positioning the client prone is not a suitable intervention for reducing discomfort caused by environmental stimuli.

2. You have been assigned to take an apical pulse for one of the patients on the nursing unit. How will you do this?

• A. You will place the stethoscope over the heart and listen for any irregular beats.
• B. You will place the stethoscope over the heart and count the beats per minute.
• C. You will place your fingertip over the patient's wrist and feel for any irregular beats.
• D. You will place your fingertip over the patient's wrist and count the beats per minute.

Correct answer: B

Rationale: To take an apical pulse accurately, you should place the stethoscope over the heart and count the number of beats per minute. This method provides a precise assessment of the heart rate. While listening for irregular beats is essential for assessing the heart's rhythm, the primary objective of taking an apical pulse is to determine the heart rate. Choices C and D are incorrect because the apical pulse is not taken at the wrist; instead, it is obtained by auscultating at the apex of the heart, usually at the point where the fifth intercostal space meets the midclavicular line.

3. After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods?

• A. Return demonstration
• B. Explanation
• C. Achievement of 90 on written test
• D. Have the client explain the procedure to the family

Correct answer: A

Rationale: After teaching the client on crutch walking technique, assessing the client's understanding is crucial. The most effective method to evaluate the client's comprehension of a hands-on skill like crutch walking technique is through a return demonstration. This allows the nurse to observe the client performing the technique, ensuring they have grasped the instructions correctly and can execute the skill safely. While providing an explanation can help clarify doubts, it may not confirm the client's ability to perform the skill. Achieving a high score on a written test assesses cognitive understanding but not necessarily the practical application of the skill. Having the client explain the procedure to the family does not directly assess their ability to perform the skill themselves; it tests their ability to communicate the information to others.

4. Which gland of the endocrine system secretes a hormone that assists with the sleep/wake cycle?

• A. Pituitary
• B. Pineal
• C. Pancreas
• D. Hypothalamus

Correct answer: B

Rationale: The correct answer is the Pineal gland. The Pineal gland, located in the brain, secretes melatonin, which plays a crucial role in regulating the sleep/wake cycle in response to exposure to light. The Pituitary gland (Choice A) secretes various hormones but not specifically related to the sleep/wake cycle. The Pancreas (Choice C) secretes insulin and digestive enzymes, not hormones related to the sleep/wake cycle. The Hypothalamus (Choice D) is involved in regulating many bodily functions, including hormone secretion, but it does not directly secrete the hormone that regulates the sleep/wake cycle.

5. What is the most useful patient position for proctologic exams?

• A. Trendelenburg
• B. Semi-Fowler's
• C. Full Fowler's
• D. Jack Knife

Correct answer: D

Rationale: The Jack Knife position is the most useful for proctologic exams as it allows the patient to lie face down while keeping the buttocks elevated, providing optimal access for the examination. The Trendelenburg position, characterized by the body being laid flat with the feet higher than the head, is not suitable for proctologic exams. Semi-Fowler's and Full Fowler's positions are typically utilized for respiratory or cardiovascular conditions and are not ideal for proctologic examinations due to their lack of optimal access to the perianal area.

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