Nursing Elites

1. Which technique or method is used to determine whether or not the patient has an irregular pulse?

• A. Apical pulse
• B. Inspection
• C. Auscultation
• D. Percussion

Correct answer: A

Rationale: An apical pulse check is used to determine if the patient has an irregular pulse. The apical pulse is located at the point of maximal impulse (PMI) and is assessed using a stethoscope. Choice B, inspection, involves visual examination and is not used to assess pulse irregularities. Choice C, auscultation, involves listening to internal sounds using a stethoscope, which can be used to assess heart sounds but not specifically for pulse irregularities. Choice D, percussion, is a technique used to assess the density of body tissues or detect abnormal masses and is not used to determine pulse irregularities.

2. A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

• A. Elevating the head of the client's bed to 30 degrees during mealtime
• B. Withholding fluids until the end of the meal
• C. Providing a 10-minute rest period prior to meals
• D. Instructing the client to place her chin toward her chest when swallowing

Correct answer: D

Rationale: The correct technique for a client with dysphagia is to instruct them to place their chin toward their chest when swallowing. This action helps to close off the airway during swallowing, reducing the risk of aspiration. Elevating the head of the client's bed to 30 degrees during mealtime helps prevent aspiration, but this is not the responsibility of the AP. Withholding fluids until the end of the meal can lead to dehydration and is not a recommended practice. Providing a 10-minute rest period prior to meals is not specifically related to improving swallowing safety for clients with dysphagia.

3. Your client has a doctor's order that reads 'advance diet as tolerated'. This client has returned from the recovery room after an appendectomy and he states, 'I am hungry'. What would you offer this client to consume?

• A. Cheese and crackers
• B. Apple sauce
• C. Chicken broth
• D. A peanut butter sandwich

Correct answer: C

Rationale: Chicken broth is a suitable option for a post-appendectomy patient beginning to tolerate oral intake. It is clear liquid and easily digestible, making it a gentle choice for someone who has just returned from surgery. Cheese and crackers, apple sauce, and a peanut butter sandwich are not ideal options for an individual who needs to start with a light and easily digestible diet.

4. What is the primary focus of primary healthcare?

• A. Emergency care
• B. Preventive care
• C. Specialized treatment
• D. Hospital-based services

Correct answer: B

Rationale: The correct answer is B: Preventive care. Primary healthcare emphasizes preventive care, which includes promoting overall health, preventing diseases, and providing early intervention to avoid the progression of illnesses. Emergency care (choice A) is focused on immediate medical attention for urgent health situations but is not the primary focus of primary healthcare. Specialized treatment (choice C) refers to care provided by specialists for specific health conditions, which is not the main focus of primary healthcare. Hospital-based services (choice D) involve inpatient care provided in a hospital setting, which is not the primary focus of primary healthcare that aims to provide comprehensive and accessible care at the community level.

5. A clinical instructor teaches a class for the public about diabetes mellitus. Which individual does the nurse assess as being at highest risk for developing diabetes?

• A. The 50-year-old client who does not engage in any physical exercise
• B. The 56-year-old client who drinks three glasses of wine daily
• C. The 42-year-old client who is 50 pounds overweight
• D. The 38-year-old client who smokes one pack of cigarettes daily

Correct answer: C

Rationale: The 42-year-old client who is 50 pounds overweight is at the highest risk for developing diabetes. Excess weight is a significant risk factor for diabetes as it can lead to insulin resistance and metabolic abnormalities. Choices A, B, and D are also risk factors for diabetes, but being overweight has a stronger association with the development of the condition compared to lack of exercise, excessive alcohol consumption, or smoking.

Similar Questions