Nursing Elites

1. A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client?

• A. Keeping the door to the client's room closed
• B. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times
• C. Placing the client in a semiprivate room with a cohort client
• D. Using a surgical mask when entering the client's room

Correct answer: A

Rationale: Evidence-based practice is an approach to client care that integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. In the case of pulmonary tuberculosis, which is transmitted through the airborne route, keeping the door to the client's room closed is crucial to prevent the spread of infection. Placing the client in a semiprivate room with a cohort client is not recommended for airborne precautions; a private room is required to prevent transmission. Fitting the client for an N95 or HEPA mask is essential for the nurse's protection when entering the room, not for the client to wear at all times. Using a surgical mask when entering the client's room is not sufficient for airborne precautions; an N95 or HEPA mask is necessary.

2. Which is the proper hand position for performing chest vibration?

• A. cup the hands
• B. use the side of the hands
• C. flatten the hands
• D. spread the fingers of both hands

Correct answer: C

Rationale: The correct hand position for performing chest vibration is to flatten the hands. By flattening the hands over the area of the body where chest percussion is applied, vibrations can be conducted effectively to the chest to help loosen secretions. Cupping the hands may dampen vibrations, using the side of the hands reduces the surface area in contact with the chest, and spreading the fingers can lead to uneven pressure distribution. Therefore, flattening the hands provides the necessary contact and surface area to perform chest vibration efficiently.

3. A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?

• A. The client's wound is healing well.
• B. The client seems anxious.
• C. The client's intake was 360 mL
• D. The client is voiding large amounts

Correct answer: C

Rationale: Quality documentation and reporting require information to be factual, accurate, complete, current, and organized. Choice C, 'The client's intake was 360 mL,' reflects the correct use of guidelines for documentation as it provides a specific and measurable observation. This note meets the criteria for quality documentation by being specific and quantifiable. Choices A, B, and D lack specificity and quantifiability. Choice A includes a subjective term 'well,' choice B uses 'seems' indicating uncertainty, and choice D uses a vague term 'large' without quantifying the amount.

4. Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?

• A. Excess Fluid Volume
• B. Risk for Aspiration
• C. Disturbed Body Image
• D. Urinary Retention

Correct answer: C

Rationale: Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy. A new colostomy can significantly impact a person's body image and self-esteem due to the physical changes it brings. This can lead to emotional distress, adjustment issues, and concerns about body image. Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are not directly related to the psychosocial impact of a new colostomy and are therefore not as relevant in this context. While Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are important nursing diagnoses, they are not the priority when considering the psychological and emotional effects of a new colostomy.

5. When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?

• A. corner of the mouth to the tragus of the ear
• B. corner of the eye to the top of the ear
• C. tip of the chin to the sternum
• D. tip of the nose to the earlobe

Correct answer: B

Rationale: Correct! When sizing an oropharyngeal airway, the nurse should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to reach the pharynx without being too long or too short. Choices B, C, and D are incorrect as they do not provide the correct anatomical landmarks for determining the size of an oropharyngeal airway. Measuring from the corner of the mouth to the tragus of the ear is a standard method to ensure proper airway size and prevent complications during airway management.

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