Nursing Elites

1. A healthcare provider is preparing to care for a client following chest tube placement. Which of the following items should NOT be available in the client's room?

• A. Oxygen
• B. Sterile water
• C. Enclosed hemostat clamps
• D. Indwelling urinary catheter

Correct answer: D

Rationale: Following chest tube placement, an indwelling urinary catheter is not typically needed or relevant to the care provided. Chest tube placement is primarily concerned with managing pleural effusion or pneumothorax, and urinary catheterization is not directly related to this procedure. Oxygen, sterile water, and enclosed hemostat clamps are commonly used items in the care of a client with a chest tube in place, to ensure proper oxygenation, maintain drainage system integrity, and manage any bleeding that may occur. Therefore, the indwelling urinary catheter should not be available in the client's room following chest tube placement.

2. A group of clients are being educated about influenza. Which of the following client statements indicates an understanding of the teaching?

• A. ''I should wash my hands after blowing my nose to prevent spreading the virus.''
• B. ''I need to avoid drinking fluids if I develop symptoms.''
• C. ''I need a flu shot every 2 years because of the different flu strains.''
• D. ''I should cover my mouth with my hand when I sneeze.''

Correct answer: A

Rationale: The correct answer is, 'I should wash my hands after blowing my nose to prevent spreading the virus.' This statement shows understanding of the importance of hand hygiene in preventing the spread of influenza. Washing hands after activities like blowing the nose can help reduce the risk of transmitting the virus to others. Choices B, C, and D are incorrect as they do not reflect accurate understanding of influenza prevention measures.

3. After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client’s vital signs. What phase of the nursing process is being implemented by the nurse?

• A. Assessment
• B. Diagnosis
• C. Planning
• D. Implementation

Correct answer: A

Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process. Choice B, 'Diagnosis,' would involve analyzing the collected data to identify the client's health problems. Choice C, 'Planning,' would be developing a plan of care based on the assessment findings. Choice D, 'Implementation,' is the phase where the nurse carries out the plan of care developed during the planning phase.

4. Before rigor mortis occurs, what is the nurse responsible for?

• A. Providing a complete bath and dressing change
• B. Placing one pillow under the body’s head and shoulders
• C. Removing the body’s clothing and wrapping the body in a shroud
• D. Allowing the body to relax normally

Correct answer: B

Rationale: Before rigor mortis occurs, the nurse is responsible for placing a pillow under the body's head and shoulders. This action helps maintain proper positioning, prevent postmortem changes, and ensure a dignified appearance. Providing a complete bath and dressing change, removing clothing, or wrapping the body in a shroud are tasks typically performed after rigor mortis sets in or later in the postmortem care process. Allowing the body to relax normally does not address the immediate need for proper positioning before rigor mortis occurs.

5. A healthcare professional is preparing to measure an infant's temperature. Which of the following actions should the healthcare professional take?

• A. Place the tip of the thermometer under the center of the infant's axilla
• B. Pull the pinna of the infant's ear forward before inserting the probe
• C. Insert the probe 3.8 cm (1.5in) into the infant's rectum
• D. Insert the thermometer in front of the infant's tongue

Correct answer: A

Rationale: When measuring an infant's temperature, the most appropriate and non-invasive method is to place the tip of the thermometer under the center of the infant's axilla (armpit). This method is safe, quick, and comfortable for the infant. Inserting the probe into the rectum is invasive and not recommended for routine temperature measurement in infants. Inserting the thermometer in front of the infant's tongue is not a reliable method for measuring temperature. Pulling the pinna of the ear forward is a technique used for adults, not infants.

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