Nursing Elites

1. Which intervention should the nurse stop the nursing assistant from performing?

• A. Emptying the Jackson-Pratt drainage of the client post cholecystectomy
• B. Performing passive range of motion on the client with right-sided paralysis
• C. Placing the traction weights on the bed to transfer the client to X-ray
• D. Discarding the first urine voided by the client starting a 24-hour urine test

Correct answer: C

Rationale: Placing traction weights on the bed to transfer the client to X-ray is an intervention that the nurse should stop the nursing assistant from performing. Traction should never be relieved without a doctor's order as it can result in muscle spasm and tissue damage. The other choices are appropriate nursing interventions and should not be stopped. Emptying the Jackson-Pratt drainage, performing passive range of motion, and collecting the first urine void for a 24-hour urine test are all within the scope of practice and do not pose immediate risks to the client's well-being.

2. Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?

• A. Stay with the client, remove the dressing, and elevate the head of bed.
• B. Call a code, open the trach set, and position the client supine.
• C. Have the client say "EEE"? to check for laryngeal integrity.
• D. Immediately go to the nurse's station and call the physician

Correct answer: A

Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say "EEE"? is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.

3. In Parkinson's disease, a client's difficulty in performing voluntary movements is known as:

• A. Akinesia.
• B. Dyskinesia.
• C. Chorea.
• D. Dystonia.

Correct answer: C.

Rationale: In Parkinson's disease, the client's difficulty in performing voluntary movements is termed dyskinesia. Dyskinesia refers to the impairment of the ability to execute voluntary muscle movements. Akinesia, on the other hand, refers to the absence or lack of voluntary movement. Chorea is characterized by involuntary, rapid, irregular movements. Dystonia involves sustained muscle contractions resulting in abnormal postures or twisting movements. Therefore, dyskinesia is the specific term used for the described difficulty in Parkinson's disease.

4. The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?

• A. 15 seconds
• B. 3 minutes
• C. 5 minutes
• D. 15 minutes

Correct answer: B

Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes. Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.

5. What is the preferred position for a client post liver biopsy procedure?

• A. Fowler's
• B. Right side
• C. Left side
• D. Prone

Correct answer: B

Rationale: The correct position for a client post liver biopsy procedure is the right side. Placing the client on the right side helps apply pressure to the liver area, which can help in holding pressure and stopping bleeding. Placing the client on the left side may not be as effective in providing direct pressure on the liver. The prone position is also not ideal for post-liver biopsy care as it does not target the liver area directly. Fowler's position, a semi-sitting position, is not typically recommended post liver biopsy as it does not provide the necessary pressure on the liver site.

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