Nursing Elites

1. During a Romberg test, the patient is asked to assume which position?

• A. Sitting
• B. Standing
• C. Genupectoral
• D. Trendelenburg

Correct answer: B

Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.

2. What is the term for the body's ability to defend itself against specific invading agents such as bacteria, toxins, viruses, and foreign bodies?

• A. Hormones
• B. Secretion
• C. Immunity
• D. Glands

Correct answer: C

Rationale: The correct answer is C: Immunity. Immunity refers to the body's ability to protect itself against specific invading agents like bacteria, toxins, viruses, and foreign bodies by recognizing and destroying them. It is a crucial defense mechanism that helps maintain health and prevent infections and diseases. Choices A, B, and D are incorrect because hormones are chemical messengers, secretion is the process of releasing substances, and glands are organs that produce and release substances, none of which specifically relate to the body's defense against invading agents.

3. When a family of an accident victim, who has been declared brain-dead, appears open to organ donation, what should the nurse do?

• A. Discourage them from deciding until their grief has eased
• B. Listen to their concerns and answer their questions truthfully
• C. Urge them to immediately sign the consent form
• D. Inform them that the body will not be available for a wake or funeral

Correct answer: B

Rationale: In situations involving potential organ donation, the nurse's role is to provide support, listen to the family's concerns, and answer their questions truthfully. By doing so, the nurse can help facilitate an informed and respectful decision-making process for the grieving family.

4. A healthcare professional is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should NOT be included in the plan of care?

• A. Encourage the client to cough every 2 hours.
• B. Check for continuous bubbling in the suction chamber.
• C. Strip the drainage tubing every 4 hours.
• D. Obtain a chest x-ray

Correct answer: C

Rationale: Stripping the drainage tubing is an outdated practice and can cause complications. Encouraging the client to cough helps with lung expansion, checking for continuous bubbling ensures proper functioning of the chest tube system, and obtaining a chest x-ray helps to assess the position of the chest tube and re-expansion of the lung. Therefore, stripping the drainage tubing every 4 hours should not be included in the plan of care.

5. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

• A. Notify the provider.
• B. Administer heparin via IV infusion.
• C. Administer oxygen therapy.
• D. Obtain a spiral CT scan.

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

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