Nursing Elites

1. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?

• A. Accompanying a client who self-administers insulin
• B. Cleansing and dressing a small decubitus ulcer
• C. Monitoring a client's response to passive range of motion exercises
• D. Applying and caring for a client's rectal pouch

Correct answer: D

Rationale: The correct answer is D because tasks like applying and caring for a client's rectal pouch are within the UAP's scope of practice, as they do not require clinical judgment. Choices A, B, and C involve more complex assessments or interventions that require clinical judgment and should be performed by licensed nursing staff.

2. After placing a stethoscope to auscultate S1 and S2 heart sounds, what should the nurse do to check for an S3 heart sound?

• A. Switch to the diaphragm of the stethoscope to hear any abnormal sounds
• B. Listen with the bell of the stethoscope at the same location
• C. Listen at a different location over the aortic area
• D. Switch to the apical area and reassess for S3 sounds

Correct answer: B

Rationale: To assess for an S3 heart sound, the nurse should listen with the bell of the stethoscope. An S3 heart sound is often low-pitched and best heard with the bell. Choice A is incorrect because switching to the diaphragm is not ideal for detecting low-pitched sounds like an S3. Choice C is incorrect as the S3 heart sound is best heard over the apex of the heart, not the aortic area. Choice D is incorrect because moving to the apical area is appropriate, but the nurse should specifically use the bell of the stethoscope to listen for S3 sounds.

3. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client’s teaching plan?

• A. Pap smear is sufficient to detect ovarian cancer
• B. Surgery is unnecessary based on negative Pap smear
• C. Further evaluation involving surgery may be needed
• D. No further tests are needed

Correct answer: C

Rationale: A negative Pap smear does not rule out ovarian cancer, which often requires more comprehensive evaluation, including imaging studies or surgery. The client should be informed that the Pap smear primarily detects cervical cancer, not ovarian cancer. Therefore, further evaluation involving imaging studies or surgery may be necessary to determine the presence of ovarian cancer. Choice A is incorrect because a Pap smear is not sufficient to detect ovarian cancer. Choice B is incorrect because surgery may be necessary for further evaluation if ovarian cancer is suspected. Choice D is incorrect because further tests are needed to confirm or rule out ovarian cancer.

4. An older adult client with gastroenteritis has been taking the antidiarrheal diphenoxylate for the past 24 hours. What finding requires the nurse to take further action?

• A. Monitor the client’s fluid intake.
• B. Obtain a stool sample for testing.
• C. Administer a laxative to clear the infection.
• D. Assess skin turgor and provide fluids.

Correct answer: D

Rationale: The correct answer is D. Assessing skin turgor is crucial as tented skin turgor indicates dehydration, which can be worsened by antidiarrheal medications like diphenoxylate. Providing fluids is essential to address dehydration in this client. Monitoring fluid intake (choice A) is important, but assessing skin turgor takes precedence in this situation. Obtaining a stool sample for testing (choice B) could be necessary for diagnostic purposes but is not the immediate priority. Administering a laxative (choice C) is contraindicated in this case as it can worsen the client's condition by further exacerbating fluid loss.

5. While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?

• A. Heart murmur.
• B. Murmur.
• C. S3 sound.
• D. S4 sound.

Correct answer: B

Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.

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