Nursing Elites

1. When preparing a patient on complete bed rest to eat, at what degree angle or more should you put the head of the bed up?

• A. 10
• B. 15
• C. 20
• D. 30

Correct answer: D

Rationale: The correct answer is D: 30. When a patient is on complete bed rest, it is essential to elevate the head of the bed at a 30-degree angle or more before meals. This position helps prevent choking and aspiration of food during eating by promoting proper swallowing and digestion. Choices A, B, and C are incorrect because they do not provide the optimal elevation needed to support safe and effective feeding for a patient on complete bed rest.

2. What technique would the nurse use to accurately assess a rectal temperature in an adult?

• A. Use a lubricated blunt tip thermometer.
• B. Insert the thermometer 2 to 3 inches into the rectum.
• C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
• D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.

Correct answer: A

Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.

3. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?

• A. Perform nursing activities throughout the entire shift
• B. Assess for signs of increased muscle tone
• C. Minimize environmental noise
• D. Teach clients to perform the Valsalva maneuver

Correct answer: C

Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.

4. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

• A. Document the amount of drainage every eight hours
• B. Obtain samples of drainage for culture from the system
• C. Assess patient pain level associated with the chest tube
• D. Check the water-seal chamber for the correct fluid level

Correct answer: A

Rationale: The correct answer is to document the amount of drainage every eight hours. UAP education typically includes tasks related to documentation of intake and output. Obtaining samples of drainage for culture and assessing patient pain level are nursing responsibilities that require licensed nursing personnel's education and scope of practice. Checking the water-seal chamber for the correct fluid level also falls under the nursing role, as it involves monitoring and maintaining the chest tube system, which requires nursing knowledge and training.

5. The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?

• A. Incomplete data
• B. Generalizing from experience
• C. Identifying with the client
• D. Lack of clinical experience

Correct answer: A

Rationale: In this scenario, the nurse is cautious about potential diagnostic errors due to incomplete data. When a client withholds information, it can lead to incomplete data, which may result in inaccurate nursing diagnoses and care planning. Therefore, the nurse's primary concern is collecting accurate data to make informed clinical decisions. Choices B, C, and D are not relevant to the situation described. Generalizing from experience, identifying with the client, and lack of clinical experience do not directly address the issue of incomplete data impacting the diagnostic process.

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