Nursing Elites

1. Prior to a thoracentesis, which of the following actions should the nurse take?

• A. Position the client in an upright position, leaning over the bedside table.
• B. Explain the procedure.
• C. Obtain ABGs.
• D. Administer benzocaine spray.

Correct answer: A

Rationale: Positioning the client in an upright position, leaning over the bedside table helps to facilitate access to the thoracic cavity during the thoracentesis procedure. This position allows for easier identification and access to the insertion site. Explaining the procedure to the client is important, but positioning is the priority. Obtaining ABGs is not directly related to the thoracentesis procedure. Administering benzocaine spray is not a standard practice before a thoracentesis.

2. In which of the following organs does the exchange of gases take place?

• A. Kidneys
• B. Lungs
• C. Liver
• D. Heart

Correct answer: B

Rationale: The exchange of gases, specifically oxygen and carbon dioxide, occurs in the lungs. In the lungs, oxygen from the air we breathe enters the bloodstream, while carbon dioxide is removed from the bloodstream and exhaled. This process is essential for respiration and supplying the body with oxygen for energy production. The kidneys filter waste from the blood to produce urine and regulate fluid balance (Choice A). The liver is involved in detoxification, protein synthesis, and producing bile (Choice C). The heart is responsible for pumping blood throughout the body to deliver oxygen and nutrients (Choice D).

3. When removing a contaminated gown, what should be the first thing touched by the nurse?

• A. Waist tie and neck tie at the back of the gown
• B. Waist tie in front of the gown
• C. Cuffs of the gown
• D. Inside of the gown

Correct answer: A

Rationale: When removing a contaminated gown, the nurse should ensure the first thing touched is the waist tie and neck tie at the back of the gown. This procedure helps prevent contamination by ensuring that the outer surface of the gown, which is likely to be contaminated, is not touched during removal. By touching the back ties first, the nurse minimizes the risk of transferring any contaminants to themselves or the environment.

4. Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?

• A. Opening the patient’s window to the outside environment
• B. Turning on the patient’s room ventilator
• C. Opening the door of the patient’s room leading into the hospital corridor
• D. Failing to wear gloves when administering a bed bath

Correct answer: D

Rationale: Failure to wear gloves during a bed bath can potentially introduce pathogens, compromising the sterile technique necessary for respiratory isolation. Proper hand hygiene and personal protective equipment are crucial to prevent the transmission of infectious agents in such settings.

5. Examples of patients suffering from impaired awareness include all of the following except:

• A. A semiconscious or overfatigued patient
• B. A disoriented or confused patient
• C. A patient who cannot care for themselves at home
• D. A patient demonstrating symptoms of drug or alcohol withdrawal

Correct answer: C

Rationale: Patients with impaired awareness may exhibit symptoms such as being semiconscious, overfatigued, disoriented, confused, or demonstrating symptoms of drug or alcohol withdrawal. A patient who cannot care for themselves at home does not necessarily indicate impaired awareness, as this could be due to physical limitations or lack of support, rather than a cognitive deficit.

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