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. What is a muscular enlarged pouch or sac that lies slightly to the left and is used for the temporary storage of food?

• A. Gallbladder
• B. Urinary bladder
• C. Stomach
• D. Lungs

Correct answer: C

Rationale: The correct answer is the stomach. The stomach is a muscular organ located slightly to the left in the abdominal cavity. It serves as a temporary storage site for food where it is mixed with digestive enzymes and acids to begin the process of digestion. The gallbladder (Choice A) is not involved in food storage; it stores bile produced by the liver. The urinary bladder (Choice B) is part of the urinary system and stores urine. The lungs (Choice D) are responsible for respiration, not food storage.

3. A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?

• A. Administer the feeding over 30 minutes
• B. Place the child in a supine position after the feeding
• C. Change the feeding bag and tubing every 3 days
• D. Warm the formula in a warm water bath before administration

Correct answer: B

Rationale: Administering the feeding over 30 minutes helps prevent complications such as aspiration. Placing the child in an upright position after the feeding is recommended to reduce the risk of aspiration. It is essential to change the feeding bag and tubing every 3 days to maintain asepsis and prevent infections. Warming the formula in a warm water bath is the correct method as using a microwave can create hot spots that may burn the child's mouth or throat.

4. A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?

• A. Oxygen equipment
• B. Incentive spirometer
• C. Pulse oximeter
• D. Sterile dressing

Correct answer: B

Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.

5. When caring for a client who is to have a line placed for hemodynamic monitoring, which statement by the newly licensed nurse indicates effectiveness of the teaching?

• A. Air should be instilled into the monitoring system after the procedure.
• B. The client should be positioned on the left side after the procedure.
• C. The transducer should be level with the second intercostal space after the line is placed.
• D. A chest x-ray is needed to verify placement after the procedure.

Correct answer: D

Rationale: After a line is placed for hemodynamic monitoring, it is crucial to confirm its correct placement. The definitive way to verify the placement is through a chest x-ray. This ensures that the line is appropriately positioned without complications. Options A, B, and C do not address the essential step of confirming the line's placement, making them incorrect choices.

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