Nursing Elites

1. You are doing bed bath to the client when suddenly, The nursing assistant rushed to the room and tell you that the client from the other room was in Pain. The best intervention in such case is:

• A. Raise the side rails, cover the client and put the call bell within reach and then attend to the client in pain to give the
• B. Tell the nursing assistant to give the pain medication to the client complaining of pain
• C. Tell the nursing assistant to go the client’s room and tell the client to wait
• D. Finish the bed bath quickly then rush to the client in Pain

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

2. Nurse DMLM is correct in identifying the correct sequence of events during abdominal assessment if she identifies which of the following?

• A. Inspection, Auscultation, Percussion, Palpation
• B. Inspection, Percussion, Palpation, Auscultation
• C. Inspection, Palpation, Percussion, Auscultation
• D. Inspection, Auscultation, Palpation, Percussion

Correct answer: D

Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation, Percussion, Palpation. Start with Inspection to observe any visible abnormalities, followed by Auscultation to listen for bowel sounds, then Percussion to assess the density of underlying structures, and finally Palpation to feel for any tenderness or masses. Choices A, B, and C have the incorrect sequence of assessment techniques.

3. To prevent injury and strain on the muscles, the nurse should observe proper body mechanics. Among the following, which is a principle of proper body mechanics?

• A. Broaden the space between the feet
• B. Push instead of pull
• C. Move the object away from the body when lifting
• D. Bend at the waist, not on the knees

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

4. Mang David, A 27 year old psychiatric client was admitted with a diagnosis of schizophrenia. During the morning assessment, Mang David shouted “Did you know that I am the top salesman in the world? Different companies want me!” As a nurse, you know that this is an example of:

• A. Hallucination
• B. Delusion
• C. Confabulation
• D. Flight of Ideas

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. In taking the client’s blood pressure, the nurse should position the client’s arm:

• A. At the level of the heart
• B. Slightly above the level of the heart
• C. At the 5th intercostals space midclavicular line
• D. Below the level of the heart

Correct answer: A

Rationale: Proper patient positioning is essential for maximizing lung expansion and promoting the drainage of secretions. Postural drainage techniques rely on gravity to help clear different lung segments, which is critical in preventing complications such as atelectasis or pneumonia in immobilized patients.

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