Nursing Elites

1. When caring for a client in the advanced stage of amyotrophic lateral sclerosis (ALS), which of the following referrals is the nurse's priority?

• A. Psychologist
• B. Social worker
• C. Occupational therapist
• D. Speech-language pathologist

Correct answer: D

Rationale: In the advanced stage of ALS, speech and swallowing difficulties become significant. As a result, the priority referral for the nurse would be a speech-language pathologist. This professional can assist in managing communication challenges and provide strategies to address swallowing issues, ensuring the client's safety and quality of life.

2. The correct method for determining the vastus lateralis site for I.M. injection is to:

• A. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
• B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
• C. Palpate a 1” circular area anterior to the umbilicus
• D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh

Correct answer: D

Rationale: The vastus lateralis site is located in the middle third of the thigh.

3. A client with vision loss is under the care of a nurse. Which of the following actions should the nurse AVOID?

• A. Keep objects in the client's room in the same place
• B. Ensure there is high-wattage lighting in the client's room
• C. Approach the client from the side
• D. Allow extra time for the client to perform tasks

Correct answer: C

Rationale: Approaching a client with vision loss from the side can startle them and may lead to accidents or discomfort. It is important to approach them from the front so they are aware of your presence. Keeping objects in the same place aids in familiarity and reduces the risk of falls. High-wattage lighting enhances visibility for the client. Allowing extra time for tasks accommodates the client's potential slower pace and ensures they can perform tasks safely.

4. A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?

• A. Instill 500 ml of solution through the NG tube.
• B. Insert a large-bore NG tube.
• C. Use a cold irrigation solution.
• D. Instruct the client to lie on their right side.

Correct answer: B

Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.

5. What is another name for the knee-chest position?

• A. Genu-dorsal
• B. Genu-pectoral
• C. Lithotomy
• D. Sim’s

Correct answer: B

Rationale: The knee-chest position is correctly identified as the genu-pectoral position. In this position, a person rests on their knees and chest with the abdomen raised and the head turned to one side. This position is commonly used in medical examinations and procedures involving the rectal or pelvic areas, allowing for better visualization and access. Choice A, 'Genu-dorsal,' is incorrect as it does not refer to the knee-chest position. Choice C, 'Lithotomy,' is incorrect as it refers to a position where the patient is lying on their back with legs flexed and feet in stirrups, commonly used during childbirth or certain surgeries. Choice D, 'Sim’s,' is incorrect as it refers to a position where the patient lies on their left side with the right knee and thigh drawn up with the left arm placed along the back.

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