Nursing Elites

1. While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?

• A. Hypoactive bowel sounds
• B. Low-pitched bowel sounds
• C. Hyperactive bowel sounds
• D. An absence of bowel sounds

Correct answer: C

Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.

2. A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push?

• A. Holding her breath and using the Valsalva maneuver
• B. Blowing repeatedly in short puffs
• C. Cleansing breaths
• D. Deep inspiration and expiration at the beginning and end, respectively, of each contraction

Correct answer: B

Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. This breathing technique allows for controlled exhalation and helps prevent unnecessary pushing. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. Holding her breath and using the Valsalva maneuver (choice A) is not recommended as it can increase intra-abdominal pressure and decrease venous return, potentially compromising fetal oxygenation. Deep inspiration and expiration at the beginning and end of each contraction (choice D) are more suitable for relaxation and oxygenation purposes rather than managing the urge to push.

3. A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?

• A. Assessing visual acuity
• B. Inspecting the eyelids for ptosis
• C. Assessing pupil constriction
• D. Assessing ocular movements

Correct answer: A

Rationale: The correct technique to assess the optic nerve is by testing visual acuity and visual fields through confrontation. Visual acuity involves assessing the clarity of vision, which directly correlates with the function of the optic nerve. Inspecting the eyelids for ptosis is unrelated to optic nerve assessment. Assessing pupil constriction is more related to the assessment of cranial nerves controlling eye movements, particularly the oculomotor nerve. Assessing ocular movements is related to testing the abducens, oculomotor, and trochlear nerves, not specifically the optic nerve.

4. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?

• A. calcium
• B. magnesium
• C. potassium
• D. sodium chloride

Correct answer: D

Rationale: The correct answer is sodium chloride. Duodenal intestinal fluid is rich in potassium (K+), sodium (Na+), and bicarbonate. When suctioning is used to remove excess fluids due to ileus, it results in the loss of sodium chloride (NaCl) leading to decreased sodium (Na+) levels. Choices A, B, and C are incorrect because calcium, magnesium, and potassium are not typically lost in significant amounts through intestinal tube suction in the context of treating ileus.

5. The client is being discharged with a prescription for an inhaled glucocorticoid for asthma. Which of the following statements indicates additional education is needed prior to discharge?

• A. "I will hold my breath for 10 seconds after each puff."?
• B. "I will wait five minutes after taking this medication and then gargle water."?
• C. "I will wait at least one minute between each puff."?
• D. "I will take this medication daily even if I am not having symptoms."?

Correct answer: B

Rationale: The correct answer is, 'I will wait five minutes after taking this medication and then gargle water.' After using an inhaled glucocorticoid, it is essential to wait for 5 minutes and then gargle water to remove any residue from the mouth, which can reduce the risk of developing thrush, a fungal infection. Choice A is correct as holding the breath for 10 seconds after each puff helps the medication reach deep into the lungs. Choice C is also correct as waiting at least one minute between puffs ensures proper delivery of the medication. Choice D is incorrect because it is important to take the medication daily as prescribed to control asthma symptoms, even if the person is not experiencing any at that moment.

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