Nursing Elites

1. When preparing the client for a thoracentesis, which action is essential for the nurse to take?

• A. Encourage the client to cough during the procedure
• B. Ask the client to void prior to the procedure
• C. Have the client lie in the prone position
• D. Determine if chest x-rays have been completed

Correct answer: B

Rationale: The essential action for the nurse to take when preparing a client for a thoracentesis is to ask the client to void prior to the procedure. This step is crucial as it helps prevent discomfort and reduces the risk of accidental injury. Encouraging the client to cough during the procedure (Choice A) is inappropriate as it can affect the accuracy of the thoracentesis. Having the client lie in the prone position (Choice C) is incorrect; the procedure is typically performed with the client sitting upright or slightly leaning forward. While determining if chest x-rays have been completed (Choice D) is important, ensuring the client has emptied their bladder is more critical for their comfort and safety during the procedure.

2. An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?

• A. Provide additional light in the room to promote sensory stimulation
• B. Teach the client to turn his head from side to side for visual scanning
• C. Place a clock and calendar in the room to improve orientation
• D. Use hand and arm gestures to improve communication and comprehension

Correct answer: B

Rationale: Teaching the client to turn his head from side to side for visual scanning is essential in addressing unilateral neglect syndrome caused by a cerebrovascular accident. This action helps improve visual awareness and assists the client in overcoming the neglect of one side of the body. Providing additional light for sensory stimulation (Choice A) may not directly address the issue of unilateral neglect. Placing a clock and calendar in the room (Choice C) may be helpful for orientation but does not specifically target unilateral neglect. Using hand and arm gestures for communication (Choice D) may aid in communication but does not directly address the visual scanning deficits associated with unilateral neglect syndrome.

3. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome?

• A. Lorazepam (Ativan)
• B. Famotidine (Pepcid)
• C. Thiamine (Vitamin B1)
• D. Atenolol (Tenormin)

Correct answer: C

Rationale: Thiamine supplementation is critical in preventing Wernicke's syndrome, especially in clients with chronic alcohol use. Wernicke's syndrome is a neurological disorder caused by thiamine deficiency. Lorazepam is a benzodiazepine used for anxiety and not for preventing Wernicke's syndrome. Famotidine is an H2 blocker used to reduce stomach acid production but does not prevent Wernicke's syndrome. Atenolol is a beta-blocker used for hypertension and angina, not for preventing Wernicke's syndrome.

4. The nurse enters the room of a client who is awaiting surgery for appendicitis. The unlicensed assistive personnel (UAP) has helped the client to a position of comfort with the right leg flexed and has applied a heating pad to the client’s abdomen to relieve the client’s pain. Which action should the nurse implement first?

• A. Remove the heating pad.
• B. Reposition the client’s right leg.
• C. Monitor for signs of inflammation.
• D. Assess the client’s pain level.

Correct answer: A

Rationale: The correct action for the nurse to implement first is to remove the heating pad. Heating pads should not be used for suspected appendicitis as they can mask symptoms and potentially worsen inflammation. Choice B is not the priority as the position of comfort chosen by the UAP may be appropriate. Monitoring for signs of inflammation (Choice C) is important but not the initial action to address the immediate issue of the heating pad. Assessing the client's pain level (Choice D) can be done after removing the heating pad to evaluate the effectiveness of pain relief measures.

5. A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?

• A. Ineffective airway clearance
• B. Altered nutrition less than body requirements
• C. Fluid volume excess
• D. Activity intolerance

Correct answer: A

Rationale: In this scenario, the highest priority nursing problem for the postoperative client following a ureterolithotomy via a flank incision is ineffective airway clearance. After surgery, there is a risk of airway obstruction due to factors like anesthesia, positioning during surgery, or the presence of secretions. Maintaining a clear airway is crucial to prevent respiratory complications, such as atelectasis or pneumonia. Altered nutrition, fluid volume excess, and activity intolerance are important considerations but are secondary to the immediate threat of compromised airway clearance in the postoperative period.

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