Nursing Elites

1. A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
• B. ''I will lie on my back with my knees bent.''
• C. ''I will rest my hand over my abdomen to create resistance.''
• D. ''I will take in a deep breath and hold it before exhaling.''

Correct answer: D

Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.

2. When assessing a client with sinusitis, which technique should the nurse use to identify manifestations of this disorder?

• A. Percussion of the frontal sinuses
• B. Auscultation of the trachea
• C. Inspection of the nasal mucosa
• D. Palpation of the orbital areas

Correct answer: D

Rationale: Sinusitis is an inflammation of the sinus cavities, which can cause tenderness and pain around the eyes (orbital areas). Palpation of the orbital areas can help identify tenderness and swelling associated with sinusitis. Auscultation of the trachea and percussion of the frontal sinuses are not relevant assessment techniques for sinusitis. Inspection of the nasal mucosa may reveal signs of inflammation, but palpation of the orbital areas is a more direct method to assess for tenderness and swelling in this specific condition.

3. If a healthcare provider administers an injection to a patient who refuses, they have committed:

• A. Assault and battery
• B. Negligence
• C. Malpractice
• D. None of the above

Correct answer: A

Rationale: When a healthcare provider administers treatment, such as an injection, against a patient's refusal or will, it constitutes assault and battery. Assault refers to the intentional act that causes a person to fear that they will be touched without consent, while battery involves the actual harmful or offensive contact. In this scenario, administering the injection without the patient's consent is both an assault (causing fear of unwanted contact) and a battery (unwanted physical contact). Therefore, the correct answer is 'Assault and battery.' Negligence refers to a failure to exercise the appropriate level of care expected in a situation, while malpractice involves professional negligence or misconduct.

4. A healthcare professional realizes that the wrong medication has been administered to a client. Which of the following actions should the healthcare professional take first?

• A. Notify the provider.
• B. Report the incident to the healthcare facility's manager.
• C. Monitor vital signs.
• D. Fill out an incident report.

Correct answer: C

Rationale: In a situation where the wrong medication has been administered to a client, the immediate priority is to assess and monitor the client's vital signs to identify any adverse effects of the incorrect medication. This action takes precedence over notifying the provider, reporting the incident, or filling out an incident report. Monitoring vital signs allows for timely recognition and intervention if the client experiences any negative reactions to the wrong medication, ensuring their safety and well-being.

5. A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?

• A. Urine output of 20 ml/hr.
• B. Montevideo units constantly at 300 mm Hg.
• C. FHR pattern showing absent variability.
• D. Contractions occurring every 5 minutes and lasting 30 seconds.

Correct answer: B

Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.

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