Nursing Elites

1. Which of the following is least important to test when assessing the client’s motor skills?

• A. strength
• B. knowledge of ergonomics
• C. balance
• D. coordination

Correct answer: B

Rationale: When assessing a client’s motor skills, it is crucial to evaluate their strength, balance, and coordination as these directly impact their motor abilities. Strength is essential to perform tasks, balance is required for stability, and coordination is necessary for smooth movements. However, knowledge of ergonomics, while beneficial for overall understanding, is not directly related to assessing motor skills. The focus should be on physical abilities rather than theoretical knowledge of ergonomics. Therefore, testing the client’s knowledge of ergonomics is the least important when evaluating their motor skills.

2. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:

• A. increase maternal fluids
• B. administer oxygen
• C. decrease maternal fluids
• D. turn the mother

Correct answer: C

Rationale: When fetal distress is indicated, interventions are aimed at improving oxygenation and blood flow to the fetus. Increasing maternal fluids helps improve blood flow and oxygen delivery, administering oxygen increases oxygenation levels, and turning the mother can help optimize fetal oxygenation. Decreasing maternal fluids would negatively impact blood volume and can worsen fetal distress, making it the exception among the listed interventions. Therefore, decreasing maternal fluids should not be performed when fetal distress is present.

3. Following abdominal surgery, a client has a nasogastric (NG) tube in place. What is the purpose of this tube immediately after surgery?

• A. simplify medication administration
• B. measure accurate input and output
• C. prevent accumulation of fluids and gas
• D. facilitate collection of specimens

Correct answer: C

Rationale: The correct answer is to prevent accumulation of fluids and gas. Immediately after abdominal surgery, the NG tube is used to keep the stomach decompressed, preventing the accumulation of fluids and gas. This helps in maintaining decompression to prevent surgical-site disruption and fluid loss through vomiting. Choices A, B, and D are incorrect because the primary purpose of the NG tube following abdominal surgery is to prevent complications related to fluid and gas build-up rather than simplifying medication administration, measuring input and output, or collecting specimens.

4. In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?

• A. ability to speak
• B. ability to hear
• C. oxygen saturation
• D. adventitious breath sounds

Correct answer: A

Rationale: In an emergency situation to assess for airway obstruction, the nurse should prioritize assessing the client's ability to speak. If a client can speak, it indicates that the airway is patent and not completely obstructed, allowing air to pass through the vocal cords for speech production. Choices B, C, and D are not the primary assessments for determining airway obstruction. Assessing the ability to hear is not directly related to an airway obstruction. While oxygen saturation and adventitious breath sounds are important in respiratory assessments, they are not the initial indicators of an airway obstruction. Oxygen saturation reflects the amount of oxygen in the blood, and adventitious breath sounds refer to abnormal lung sounds that may indicate conditions like pneumonia or bronchitis, but they do not specifically confirm airway patency.

5. Which is the proper hand position for performing chest percussion?

• A. Use the side of the hands
• B. Flatten the hands
• C. Spread the fingers of both hands
• D. Cup the hands

Correct answer: D

Rationale: The proper hand position for performing chest percussion is to cup the hands. Cupping the hands helps produce a vibration that aids in loosening respiratory secretions effectively. This technique is essential for therapeutic chest physiotherapy. Using the side of the hands, flattening the hands, or spreading the fingers of both hands do not generate the necessary vibration required for chest percussion. These hand positions are not considered proper techniques in this context and may not provide the desired therapeutic effect.

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