Nursing Elites

1. Which of the following items of subjective client data would be documented in the medical record by the nurse?

• A. Client's face is pale
• B. Cervical lymph nodes are palpable
• C. Nursing assistant reports client refused lunch
• D. Client feels nauseated

Correct answer: D

Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition. Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse. Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.

2. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?

• A. Get the nurse who is caring for the patient.
• B. Tell the nurse that the patient has had another seizure.
• C. Observe the patient for any injuries and call out for help.
• D. Nothing. This patient is not one of your assignments.

Correct answer: C

Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.

3. A client is being assisted with ambulation in the hallway using a gait belt when they become dizzy and start to faint. What is the first action the nurse should take?

• A. Stand behind the client and prepare to catch them if they fall
• B. Assist the client to sit in the nearest chair or slide down along a wall
• C. Grasp the client under the arms and pull them upward
• D. Call for help from nearby staff

Correct answer: A

Rationale: If a client becomes dizzy and starts to faint while being assisted with ambulation, the nurse's first action should be to assist the client into a sitting position to prevent or reduce the impact of a fall. This can be done by guiding the client to sit in the nearest chair or sliding down along a wall for support. Option A is incorrect because standing behind the client may not prevent a fall and could potentially lead to injury. Option C is incorrect as pulling the client upward may worsen the situation. Option D, calling for help, is not the first action to take when the client is at risk of falling.

4. Where is the Loop of Henle located in the body?

• A. Liver
• B. Kidney
• C. Heart
• D. Ear

Correct answer: B

Rationale: The Loop of Henle is a crucial structure found in the kidneys. It plays a vital role in the concentration of urine by creating a concentration gradient in the renal medulla. Choices A, C, and D are incorrect because the Loop of Henle is not located in the liver, heart, or ear. Understanding the anatomical location of the Loop of Henle is essential in comprehending renal physiology and the mechanism of action of diuretic medications.

5. When assessing a pulse, what should be noted?

• A. Rate
• B. Rate and quality
• C. Rate, quality, and fullness
• D. Rate, quality, fullness, and regularity

Correct answer: C

Rationale: When assessing a pulse, it is important to note the rate (number of beats per minute), quality (regular or irregular), and fullness (thread and weak or full and bounding). These aspects provide crucial information about the patient's cardiovascular status. Regularity, as mentioned in option D, is not typically assessed during a pulse check and is not necessary for routine pulse assessment. Choice A is too limited as it overlooks important aspects beyond just the rate. Choice B improves by adding quality but still lacks the fullness aspect. Choice C is the most comprehensive and accurate as it includes all three essential aspects for a thorough pulse assessment.

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