Nursing Elites

1. A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client?

• A. Supine
• B. Standing
• C. Lithotomy
• D. Left lateral

Correct answer: D

Rationale: For a rectal examination in a female client, the nurse should assist the client into the left lateral position. This position allows easier access to the rectal area, facilitating the examination. The lithotomy position is used for examining the genitalia and rectum in females, not solely for a rectal examination. The standing position is not appropriate for a rectal examination as it does not provide the necessary access. The supine position would hinder the effectiveness of a rectal examination as it does not optimize access to the rectal area.

2. All of the following are common reasons that nurses are reluctant to delegate except:

• A. lack of self-confidence.
• B. desire to maintain authority.
• C. confidence in subordinates.
• D. getting trapped in the 'I can do it better myself' mindset.

Correct answer: C

Rationale: The correct answer is 'confidence in subordinates.' If a delegator has confidence in their subordinates' abilities, they are more likely to delegate tasks. Reasons why nurses are reluctant to delegate include their own lack of self-confidence, the desire to maintain authority, and getting trapped in the 'I can do it better myself' mindset. Therefore, having confidence in subordinates is not a common reason for reluctance to delegate.

3. When a 25-year-old client complains of chest congestion and cough after previously presenting with cold symptoms, what data should the nurse collect?

• A. Data related to follow-up care
• B. A complete health database
• C. Data related to the respiratory system
• D. Data related to the treatment for the cold

Correct answer: C

Rationale: In this case, the nurse should collect data related to the respiratory system since the client is presenting with symptoms like chest congestion and cough, indicating a respiratory issue. Focusing on the respiratory system will help gather pertinent information to assess the current problem comprehensively. A complete health database involves a detailed health history and full physical examination, which is beyond the immediate scope of the presenting issue. Data related to follow-up care is premature as the primary focus should be on assessing the current respiratory symptoms. Data related to the treatment for the cold is not the priority at this stage, as understanding the underlying respiratory problem is crucial for appropriate intervention.

4. A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push?

• A. Holding her breath and using the Valsalva maneuver
• B. Blowing repeatedly in short puffs
• C. Cleansing breaths
• D. Deep inspiration and expiration at the beginning and end, respectively, of each contraction

Correct answer: B

Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. This breathing technique allows for controlled exhalation and helps prevent unnecessary pushing. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. Holding her breath and using the Valsalva maneuver (choice A) is not recommended as it can increase intra-abdominal pressure and decrease venous return, potentially compromising fetal oxygenation. Deep inspiration and expiration at the beginning and end of each contraction (choice D) are more suitable for relaxation and oxygenation purposes rather than managing the urge to push.

5. A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?

• A. a banana
• B. grapefruit
• C. a salami sandwich
• D. avocado slices

Correct answer: B

Rationale: The correct answer is grapefruit. Clients taking MAO Inhibitors like phenelzine (Nardil) should avoid foods rich in tyramine to prevent hypertensive crisis. Grapefruit is a suitable choice as it is not high in tyramine. Bananas, avocados, and salami are foods that should be avoided due to their tyramine content, which can interact adversely with MAO Inhibitors. Therefore, choosing grapefruit is the safest option for the client.

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