Nursing Elites

1. During the removal of a chest tube, what should the nurse instruct the client to do?

• A. Lie on their left side.
• B. Use the incentive spirometer.
• C. Cough at regular intervals.
• D. Perform the Valsalva maneuver.

Correct answer: D

Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.

2. What is the best description of Back Care?

• A. Caring for the back by means of massage
• B. Washing the back
• C. Applying a cold compress to the back
• D. Applying a hot compress to the back

Correct answer: A

Rationale: The correct answer is A: Caring for the back by means of massage. Back Care involves activities like massage, exercises, maintaining proper posture, and using ergonomic practices to keep the spine healthy and prevent injuries. While washing the back is a hygiene practice, applying cold or hot compresses may provide relief for back pain but do not encompass the comprehensive approach of back care like massage does.

3. A healthcare professional is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the healthcare professional NOT expect to be at risk?

• A. Client who has dysphagia
• B. Client who has AIDS
• C. Client who was vaccinated for pneumococcus and influenza 6 months ago
• D. Client who has a closed head injury and is receiving ventilation

Correct answer: C

Rationale: A client who was vaccinated for pneumococcus and influenza 6 months ago would have a reduced risk of developing pneumonia compared to those who have not been vaccinated. Vaccination helps protect individuals from specific pathogens, thereby lowering the risk of infection. Clients with dysphagia, AIDS, or a closed head injury and receiving ventilation are at higher risk for pneumonia due to compromised immunity, respiratory function, or protective airway reflexes, respectively.

4. Which of the following principles of primary nursing has proven most satisfying to the patient and nurse?

• A. Continuity of patient care promotes efficient and cost-effective nursing care.
• B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
• C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
• D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

Correct answer: D

Rationale: The holistic approach, encompassing a therapeutic relationship, continuity, and efficient nursing care, is the most satisfying principle of primary nursing. This approach considers the patient as a whole, taking into account physical, emotional, social, and spiritual aspects, which enhances the nurse-patient relationship and promotes comprehensive care. It emphasizes individualized care delivery, continuity of care, and an integrated approach, leading to improved patient satisfaction and nurse fulfillment.

5. When is the most appropriate time for obtaining a sputum specimen for culture?

• A. Early in the morning
• B. After the patient eats a light breakfast
• C. After aerosol therapy
• D. After chest physiotherapy

Correct answer: A

Rationale: Obtaining a sputum specimen early in the morning is the most appropriate time because secretions have accumulated overnight. This timing provides the best sample with the least contamination, leading to more accurate culture results and aiding in diagnosing respiratory infections effectively.

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