Nursing Elites

1. What special consideration should be taken into account when Mario prepares Richard for postural drainage and percussion?

• A. Monitoring a respiratory rate of 16 to 20 per minute
• B. Assessing the client's ability to tolerate sitting and lying positions
• C. Ensuring the client is free of signs of infection
• D. Knowing the time of the client's last food and fluid intake

Correct answer: A

Rationale: The correct answer is A, 'Monitoring a respiratory rate of 16 to 20 per minute'. When performing postural drainage and percussion, it is crucial to monitor the respiratory rate to ensure the safety and effectiveness of the procedure. Choice B, 'Assessing the client's ability to tolerate sitting and lying positions', while important, is not directly related to the specifics of postural drainage and percussion. Similarly, option C, 'Ensuring the client is free of signs of infection', although important, is not directly linked to the procedure. Option D, 'Knowing the time of the client's last food and fluid intake', might be relevant for other procedures, but it is not the primary consideration for postural drainage and percussion.

2. What food would most likely be included in Level 1 of the National Dysphagia Diet?

• A. peanut butter
• B. oatmeal
• C. fruit preserves
• D. plain yogurt

Correct answer: D

Rationale: The correct answer is D, plain yogurt. Level 1 of the National Dysphagia Diet includes pureed or smooth foods that are easy to swallow. Plain yogurt fits this criteria as it is smooth and can be easily consumed without posing a risk of choking. Choices A, B, and C are not typically included in Level 1 of the diet. Peanut butter, oatmeal, and fruit preserves are not usually suitable for individuals on Level 1 of the National Dysphagia Diet as they may present a choking hazard or are not in a pureed or smooth form.

3. A multivitamin supplement containing folic acid is recommended for all young women because of the number of unintentional pregnancies in women 15 to 24 years old.

• A. Both the statement and the reason are correct and related
• B. Both the statement and the reason are correct but are not related
• C. The statement is correct, but the reason is not correct
• D. The statement is not correct, but the reason is correct

Correct answer: A

Rationale: Both the statement and the reason are correct and related. A multivitamin with folic acid is recommended for young women due to the high incidence of unplanned pregnancies in this age group.

4. In conducting a cleansing enema, how does the nurse position the client?

• A. Right lateral position
• B. Left lateral position
• C. Right Sim's position
• D. Left Sim's position

Correct answer: B

Rationale: In preparing a patient for a cleansing enema, the nurse typically positions the patient in the left lateral position. This position allows for the best flow of the solution due to the anatomical configuration of the colon. The right lateral position, right Sim's position, and left Sim's position are not typically used for this procedure. The rationale provided initially is incorrect as it pertains to lung expansion and postural drainage, which are not relevant to a cleansing enema procedure.

5. The breakdown in teamwork is often times a failure in:

• A. Electricity
• B. Inadequate supply
• C. Leg work
• D. Communication

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

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