Nursing Elites

1. The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use?

• A. Supine position
• B. Lateral position
• C. Lateral position with positioning supports
• D. Supine position with no pillow under the patient's head

Correct answer: B

Rationale: When assessing body alignment for an immobilized patient, the nurse should use the lateral position. This position helps in assessing alignment and preventing complications such as pressure ulcers. The supine position (Choice A) may not provide an accurate assessment of body alignment in an immobilized patient. While a lateral position with positioning supports (Choice C) may be used for comfort, it is not specifically for assessing body alignment. Using the supine position without a pillow under the patient's head (Choice D) is not ideal for assessing body alignment in an immobilized patient as it may not accurately reflect the patient's overall alignment.

2. In a client with liver cirrhosis, which symptom would be most concerning during assessment?

• A. Jaundice
• B. Ascites
• C. Hepatomegaly
• D. Altered mental status

Correct answer: D

Rationale: Altered mental status would be the most concerning symptom in a client with liver cirrhosis. It may indicate hepatic encephalopathy, a serious complication requiring immediate intervention. While jaundice, ascites, and hepatomegaly are common in liver cirrhosis, they do not directly correlate with the urgency and severity of hepatic encephalopathy as altered mental status does. Therefore, altered mental status takes priority for immediate attention and intervention.

3. During a Weber test, what is an appropriate action for the nurse to take?

• A. Deliver a series of high-pitched sounds at random intervals.
• B. Place an activated tuning fork in the middle of the client's forehead.
• C. Hold an activated tuning fork against the client's mastoid process.
• D. Whisper a series of words softly into one ear.

Correct answer: B

Rationale: During a Weber test, the nurse should place an activated tuning fork in the middle of the client's forehead. This test is used to assess for lateralization of sound in a client with possible hearing issues. Choice A is incorrect because the Weber test does not involve delivering high-pitched sounds at random intervals. Choice C is incorrect as it describes the Rinne test, not the Weber test. Choice D is incorrect as whispering words into one ear is not part of the Weber test procedure.

4. During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?

• A. Fat
• B. Fluid
• C. Flatus
• D. Hernias

Correct answer: D

Rationale: The correct answer is 'Hernias.' Abdominal distention with a midline protrusion, taut skin, and no involvement of the flanks is characteristic of hernias. Hernias are caused by a weakness in the abdominal wall, allowing organs or tissues to protrude through. Fluid accumulation (ascites) typically presents with a more generalized distention, while fat accumulation may cause more diffuse distension rather than a focal midline protrusion. Flatus, or gas, would not typically present with a visible midline protrusion and taut skin like hernias.

5. A client has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

• A. Monitor blood glucose levels daily.
• B. Change the PN infusion bag every 24 hours.
• C. Prepare the client for a central venous line.
• D. Administer the PN and fat emulsion together.

Correct answer: C

Rationale: When a client requires parenteral nutrition (PN) with a high dextrose concentration, such as 20%, it typically has a high osmolarity. High osmolarity solutions should be infused through a central venous line to prevent peripheral vein irritation and potential complications. Therefore, preparing the client for a central venous line is essential for the safe administration of PN with high dextrose. Monitoring blood glucose levels daily is important but not directly related to the need for a central venous line. Changing the PN infusion bag every 24 hours helps prevent bacterial contamination, but it is not the most critical action in this scenario. Administering the PN and fat emulsion together or separately is a matter of compatibility and administration guidelines, but it is not the key concern in this situation.

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