Nursing Elites

1. The nurse observes a UAP performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the nurse take?

• A. Stop the procedure and tell the UAP to place the client in a Fowler's position
• B. Praise the UAP for doing the oral hygiene but encourage family participation
• C. Tell the UAP to continue because the unconscious client is positioned safely
• D. Enroll the UAP in a hospital education class on conducting safe client care

Correct answer: C

Rationale: The correct answer is to tell the UAP to continue because the unconscious client is positioned safely for oral care. Placing an unconscious client in a side-lying position helps prevent aspiration, and having an emesis basin under the chin is appropriate to catch any fluids. Therefore, the nurse should acknowledge that the UAP is performing the procedure correctly. Choices A, B, and D are incorrect. Placing the client in a Fowler's position is not necessary for this procedure as the client is already positioned safely. Praise and encouragement for family participation are important aspects but not the immediate action needed in this scenario. Enrolling the UAP in a hospital education class is not warranted as the current procedure is being performed correctly.

2. A client tells the PN that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce her risk of getting cancer. How should the PN respond?

• A. Encourage the client to get plenty of exercise in addition to the dietary change
• B. Provide written information about the seven warning signs of cancer
• C. Remind the client to ensure that the dairy products are fortified with Vitamin D
• D. Suggest that an increase in fruits and vegetables is more beneficial

Correct answer: D

Rationale: Increasing fruits and vegetables in the diet is more beneficial in reducing cancer risk due to their high levels of antioxidants and fiber, which help protect against cancer. While exercise is important for overall health, in this context, focusing on fruits and vegetables is more relevant to reducing cancer risk than exercise alone. Providing information about cancer warning signs is not directly addressing the client's dietary choice. While Vitamin D is essential for various health aspects, the primary focus here should be on a diet rich in fruits and vegetables for cancer risk reduction.

3. A client post-thoracotomy is complaining of severe pain with deep breathing and coughing. What should the nurse encourage the client to do to manage the pain and prevent respiratory complications?

• A. Hold a pillow against the chest while coughing (splinting).
• B. Take shallow breaths to avoid pain.
• C. Increase the dose of pain medication.
• D. Avoid deep breathing exercises.

Correct answer: A

Rationale: Splinting the chest with a pillow helps manage pain during deep breathing and coughing, which is essential to prevent respiratory complications such as atelectasis or pneumonia after thoracic surgery. Holding a pillow against the chest while coughing (splinting) supports the incision site and reduces the pain associated with deep breathing and coughing. Encouraging shallow breaths (Choice B) can lead to respiratory complications due to inadequate lung expansion. Increasing pain medication (Choice C) should be done based on healthcare provider orders and not solely for this situation. Avoiding deep breathing exercises (Choice D) can worsen respiratory function and increase the risk of complications.

4. Which type of cell is responsible for producing antibodies in the immune system?

• A. B lymphocytes
• B. T lymphocytes
• C. Macrophages
• D. Neutrophils

Correct answer: A

Rationale: The correct answer is A: B lymphocytes. B lymphocytes (B cells) are a crucial part of the adaptive immune system. They produce antibodies, which are proteins that specifically target and neutralize pathogens such as bacteria and viruses. T lymphocytes (choice B) are involved in cell-mediated immunity rather than antibody production. Macrophages (choice C) are phagocytic cells that engulf and digest pathogens but do not produce antibodies. Neutrophils (choice D) are a type of white blood cell that primarily function in the innate immune response by phagocytosing pathogens.

5. A client with peripheral neuropathy due to cirrhosis is at risk for injury. What should the nurse do?

• A. Protect the client's feet from injury
• B. Apply a heating pad to the affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is critical as peripheral neuropathy can lead to decreased sensation and increased risk of trauma. This measure helps prevent wounds, ulcers, and other complications. Applying a heating pad (Choice B) can worsen symptoms and cause burns due to decreased sensation. Keeping the client's feet elevated (Choice C) may help reduce swelling but does not directly address the risk of injury. Assessing for jaundice (Choice D) is important in cirrhosis but is not directly related to the client's risk of injury due to peripheral neuropathy.

Similar Questions