Nursing Elites

1. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?

• A. Side-lying on the left with the head elevated 10 degrees
• B. Side-lying on the left with the head elevated 35 degrees
• C. Side-lying on the right with the head elevated 10 degrees
• D. Side-lying on the right with the head elevated 35 degrees

Correct answer: A

Rationale: The correct position for a client with viral pneumonia affecting 2/3 of the right lung is side-lying on the left with the head elevated 10 degrees. This position helps maximize lung expansion and oxygenation in cases of pneumonia affecting the right lung. Choice B is incorrect as excessive elevation can put pressure on the lung, and choices C and D are incorrect as side-lying on the right would not be beneficial for a client with pneumonia in the right lung.

2. A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client?

• A. It is a condition in which one or more tumors, called gastrinomas, form in the pancreas or in the upper part of the small intestine (duodenum).
• B. It is critical to promptly report any findings of peptic ulcers to your health care provider.
• C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors.
• D. The average age at diagnosis is 50 years, and peptic ulcers may occur in unusual areas of the stomach or intestine.

Correct answer: B

Rationale: Prompt reporting of peptic ulcers is crucial in managing Zollinger-Ellison syndrome to prevent complications and guide treatment. While choices A, C, and D provide relevant information about the condition and its treatment, the most important aspect in the client's care is the prompt reporting of peptic ulcers. This is because untreated peptic ulcers in Zollinger-Ellison syndrome can lead to serious complications such as gastrointestinal bleeding or perforation. Therefore, ensuring timely communication with the healthcare provider is essential for effective management of the condition.

3. A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?

• A. Monitor the client's temperature
• B. Assess the client's pain level
• C. Check the intravenous (IV) site for signs of phlebitis
• D. Monitor the client's respiratory status

Correct answer: C

Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.

4. A nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect?

• A. Decreased deep-tendon reflexes
• B. Skeletal muscle weakness
• C. Hypoactive bowel sounds
• D. Tingling of the lips

Correct answer: D

Rationale: The correct answer is D, tingling of the lips (perioral tingling). This is a common symptom of hypocalcemia due to increased neuromuscular excitability. Choice A, decreased deep-tendon reflexes, is more indicative of hypercalcemia. Choice B, skeletal muscle weakness, is associated with hypokalemia. Choice C, hypoactive bowel sounds, is not a typical finding in hypocalcemia.

5. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

• A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
• B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate.
• C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
• D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.

Correct answer: A

Rationale: The most crucial point to reinforce to the patient after a vasectomy is the need for continued contraception until it is confirmed that the ejaculate is sperm-free. Choice A emphasizes this by highlighting the importance of using another form of contraception until the healthcare provider confirms the absence of sperm. This is essential to prevent unintended pregnancies. Choices B, C, and D do not address the key point of ensuring contraception until sperm absence is confirmed and are therefore not as important to reinforce in this scenario.

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