Nursing Elites

1. During the removal of a chest tube, what should the nurse instruct the client to do?

• A. Lie on their left side.
• B. Use the incentive spirometer.
• C. Cough at regular intervals.
• D. Perform the Valsalva maneuver.

Correct answer: D

Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.

2. 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.

3. A healthcare professional is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the healthcare professional make in the medical record?

• A. Morphine 3 mg Subcutaneous every 4 hr. PRN for pain.
• B. Morphine 3 mg Subcutaneous
• C. Morphine 3.0 mg subcutaneously every 4 hr. PRN for pain.
• D. Morphine 3 mg Subcutaneous q 4 hr. PRN for pain.

Correct answer: D

Rationale: The correct entry for documenting the prescription for morphine is 'Morphine 3 mg Subcutaneous'. This entry accurately specifies the medication, dosage, route of administration, and frequency as prescribed by the provider. Options A, C, and D contain minor errors such as missing units of measurement or incorrect abbreviations, which could lead to misinterpretation or potential medication errors. Therefore, the most appropriate and accurate choice is 'Morphine 3 mg Subcutaneous'.

4. What is the initial technique used when examining a client's abdomen?

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

Correct answer: D

Rationale: When examining a client's abdomen, the initial technique used is inspection. Inspection involves visually assessing the abdomen for any abnormalities, such as distention, scars, or rashes. This step allows the healthcare provider to gather valuable information before proceeding to other examination techniques like palpation, auscultation, and percussion. Palpation, auscultation, and percussion are secondary techniques used after visual inspection to further assess the abdomen for specific findings. Palpation involves feeling the abdomen for masses or tenderness, auscultation is listening for bowel sounds, and percussion is tapping the abdomen to assess for areas of dullness or resonance.

5. How can preserving skin integrity impact the circular chain of infection?

• A. Host
• B. Reservoir
• C. Mode of transmission
• D. Portal of entry

Correct answer: D

Rationale: Preserving skin integrity plays a key role in breaking the chain of infection by eliminating the portal of entry for pathogens. When the skin is intact, it acts as a natural barrier that prevents pathogens from entering the body. By maintaining skin integrity through proper hygiene and wound care, the risk of infection is significantly reduced, disrupting the cycle of infection transmission.

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