Nursing Elites

1. The mother of a toddler calls the nurse for help as the baby is choking on his food. The nurse determines that the Heimlich maneuver is necessary based on which finding?

• A. Inability of the toddler to cry or speak
• B. Coughing forcefully
• C. Gagging but able to breathe
• D. Wheezing during respiration

Correct answer: A

Rationale: The correct answer is option A: Inability of the toddler to cry or speak. In cases of choking, the inability to cry or speak indicates a severe airway obstruction where the Heimlich maneuver is necessary to clear the obstruction and establish a patent airway. Option B, coughing forcefully, represents a partial obstruction where the child can still move air, making the Heimlich maneuver not immediately necessary. Option C, gagging but able to breathe, suggests a partial obstruction where air is moving, and the child can still breathe, not requiring immediate intervention like the Heimlich maneuver. Option D, wheezing during respiration, is more indicative of a lower airway issue such as asthma rather than an upper airway obstruction that necessitates the Heimlich maneuver.

2. When providing mouth care for an unconscious client, what action should the nurse take?

• A. Turn the client’s head to the side.
• B. Place two fingers in the client’s mouth to open it.
• C. Brush the client’s teeth once per day.
• D. Inject mouth rinse into the center of the client’s mouth.

Correct answer: A

Rationale: When providing mouth care for an unconscious client, the nurse should turn the client’s head to the side. This action helps prevent aspiration by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Placing fingers into the client’s mouth can be dangerous and may cause injury. Brushing the client’s teeth only once a day may not be sufficient for proper oral hygiene care. Injecting mouth rinse into the center of the mouth is not recommended and can potentially lead to aspiration. Therefore, the correct action for the nurse to take is to turn the client’s head to the side.

3. During an admission history assessment, a client informs the nurse about consuming herbal tea every afternoon at work to alleviate stress. What ingredient is likely present in the tea?

• A. Chamomile
• B. Ginseng
• C. Ginger
• D. Echinacea

Correct answer: A

Rationale: The correct answer is A: Chamomile. Chamomile tea is commonly used for stress relief. Choice B, Ginseng, is not typically used in teas for stress relief but for energy and immune system support. Choice C, Ginger, is more commonly used for digestive health and nausea. Choice D, Echinacea, is often used to boost the immune system. Therefore, in the context of stress relief, Chamomile is the most appropriate ingredient.

4. During a dressing change, a healthcare professional observes granulation tissue in a client's wound. Which of the following findings should be documented?

• A. Stringy, white tissue
• B. Translucent, red tissue
• C. Soft, yellow tissue
• D. Thick, black tissue

Correct answer: B

Rationale: Granulation tissue is a hallmark of healing in wounds. It appears as translucent and red, indicating angiogenesis and the formation of new blood vessels in the wound bed. This tissue is vital for wound healing as it provides a scaffold for cell migration and promotes re-epithelialization. Choices A, C, and D do not describe granulation tissue accurately. Stringy, white tissue may suggest fibrin, soft, yellow tissue could indicate slough, and thick, black tissue may imply necrotic tissue, all of which are not synonymous with granulation tissue and do not signify the healing process.

5. During a complete bed bath for a client, after removing the gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?

• A. Face
• B. Feet
• C. Chest
• D. Arms

Correct answer: A

Rationale: When performing a complete bed bath, it is essential to wash the face first. Washing the face initially helps to maintain the client's privacy and comfort. Additionally, starting with the face prevents re-contamination of already cleaned areas. Washing the feet first (Choice B) is not ideal as it can lead to potential contamination of the upper body parts. Starting with the chest (Choice C) or arms (Choice D) is not recommended due to the risk of water dripping onto the client's face, causing discomfort and compromising privacy.

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