Nursing Elites

1. The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

• A. Place a pillow under the patient's lower legs.
• B. Turn the head toward one side with a large, soft pillow.
• C. Position legs flat against the bed.
• D. Raise the head of the bed to 45 degrees.

Correct answer: A

Rationale: Placing a pillow under the patient's lower legs when in the prone position is essential to allow dorsiflexion of the ankles and some knee flexion, which promote relaxation. This position also helps in maintaining proper alignment of the spine. Options B, C, and D are incorrect because turning the head, positioning legs flat against the bed, and raising the head of the bed to 45 degrees are not appropriate actions for a patient in the prone position. Turning the head to one side with a large, soft pillow is commonly done for patients in the supine position to maintain proper alignment and airway patency. Positioning legs flat against the bed is more suitable for a patient in a supine or semi-fowler's position. Raising the head of the bed to 45 degrees is typically done for patients who need semi-fowler's positioning for respiratory support or to prevent aspiration.

2. A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following techniques should the nurse identify as indicating the correct method for eliciting the client's patellar reflex?

• A. Tap just below the knee
• B. Tap on the upper thigh
• C. Tap on the ankle
• D. Tap on the lower leg

Correct answer: A

Rationale: The correct technique for eliciting the client's patellar reflex is to tap just below the knee. This action stimulates the stretch receptors in the patellar tendon, leading to a reflex contraction of the quadriceps muscle and extension of the lower leg. Tapping on the upper thigh (Choice B) would not elicit the patellar reflex as it targets a different area. Similarly, tapping on the ankle (Choice C) or tapping on the lower leg (Choice D) would not produce the desired response associated with the patellar reflex, making them incorrect choices.

3. A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members?

• A. Charge nurse
• B. Registered nurse (RN)
• C. Practical nurse (PN)
• D. Assistive personnel (AP)

Correct answer: B

Rationale: In this scenario, a client who has undergone thoracic surgery and is being admitted from the PACU requires a high level of nursing care. Registered nurses (RNs) have the education and training necessary to provide the complex care and monitoring needed for a post-thoracic surgery client. Charge nurses may oversee units but may not always be directly involved in providing bedside care. Practical nurses (PNs) have a different scope of practice compared to RNs and may not have the advanced skills needed for post-thoracic surgery care. Assistive personnel (AP) provide valuable support but do not have the qualifications to manage the care of a client following thoracic surgery.

4. A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

• A. Not offering a backrub to a patient with fractured ribs
• B. Not offering to wash the hair of a patient with neck trauma
• C. Turning off the television while giving a backrub to the patient
• D. Turning the patient's head with neck injury to the side when giving oral care

Correct answer: D

Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.

5. A client has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should be administered to soften the feces?

• A. Oil retention
• B. Soapsuds
• C. Saline
• D. Hypertonic

Correct answer: A

Rationale: An oil retention enema is the most appropriate choice to soften and lubricate the feces before digital removal. Oil retention enemas help in making the stool easier to remove digitally due to their lubricating properties. Soapsuds, saline, and hypertonic enemas are not specifically designed to soften feces and are used for different purposes. Soapsuds enemas are used for cleansing, saline enemas for bowel evacuation, and hypertonic enemas for bowel distension in preparation for diagnostic procedures.

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