Nursing Elites

1. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:

• A. Client lying on his back then flat on his abdomen on Trendelenburg position
• B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his
• C. Client lying flat on his back and then flat on his abdomen
• D. Client lying on his right then left side on Trendelenburg position

Correct answer: A

Rationale: Proper patient positioning is essential for maximizing lung expansion and promoting the drainage of secretions. Postural drainage techniques rely on gravity to help clear different lung segments, which is critical in preventing complications such as atelectasis or pneumonia in immobilized patients.

2. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

• A. Ensure that the bed linen is always dry
• B. Frequently check the bed for wetness and keep it dry
• C. Place a rubber sheet under the client's buttocks
• D. Keep the patient clean and dry

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

3. Maria’s statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” is an example of:

• A. Delusion of grandeur
• B. Visual Hallucination
• C. Religious delusion
• D. Auditory Hallcucination

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

4. A client who underwent surgical placement of a colostomy is being cared for by a nurse. Which of the following statements indicates the client understands the dietary teaching?

• A. "Eating yogurt can help decrease the amount of gas that I have."?
• B. "I should eliminate pasta from my diet so that I don't have as many loose stools."?
• C. "My largest meal of the day should be in the evening."?
• D. "Carbonated beverages can help control odor."?

Correct answer: D

Rationale: The correct answer is D. Carbonated beverages can help control odor in clients with colostomies. This is because carbonated drinks can help decrease odor by reducing the production of odoriferous compounds in the colon. Choices A, B, and C are incorrect. Eating yogurt may help regulate bowel movements but does not specifically address odor control associated with colostomies. Eliminating pasta from the diet to reduce loose stools is not necessary for colostomy care. The timing of the largest meal of the day is not directly related to dietary teaching for colostomy care.

5. Studies suggest that leukoplakia is resolved by excess vitamin A (a fat-soluble vitamin), retinoids, and beta-carotene. Leukoplakia is a white plaque that forms on oral mucous membranes.

• A. Both statements are true.
• B. Both statements are false.
• C. The first statement is true; the second is false.
• D. The first statement is false; the second is true.

Correct answer: B

Rationale: Both statements are false. Studies suggest that leukoplakia, a white plaque that forms on oral mucous membranes, can be resolved by vitamin A, retinoids, and beta-carotene. Despite the potential to resolve leukoplakia, relapse is common. Also pertinent, evidence does not indicate that any of these nutrients prevent malignant transformation. The extract provided clarifies that leukoplakia is a white plaque, not an erythematous lesion, and that vitamin A, retinoids, and beta-carotene can help resolve it.

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