Nursing Elites

1. A client with a chest tube following thoracic surgery needs care. Which task should the nurse delegate to an assistive personnel?

• A. Teach deep breathing and coughing to the client.
• B. Assist the client to select food choices from the menu.
• C. Evaluate the client’s response to pain medication.
• D. Monitor the characteristics of the client's chest tube drainage.

Correct answer: B

Rationale: The correct answer is B because assisting the client with food choices is a task that can be safely delegated to assistive personnel. This task does not require nursing judgment or specialized skills. Choices A, C, and D involve assessing the client's condition, response to treatment, and monitoring critical aspects of care, which are nursing responsibilities that necessitate specialized knowledge and judgment. Teaching deep breathing and coughing (A), evaluating pain medication response (C), and monitoring chest tube drainage (D) require a higher level of training and expertise that should be performed by the nurse.

2. A client in an oncology clinic is being assessed by a nurse while undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

• A. I keep having nightmares about my upcoming surgery.
• B. I feel more energetic than I did before.
• C. I have been making plans for the future.
• D. I am looking forward to starting my new treatment.

Correct answer: A

Rationale: Choice A is the correct answer as nightmares about upcoming surgery indicate psychological distress commonly associated with fears, anxiety, and stress related to the treatment. Choices B, C, and D suggest positive emotions and proactive behaviors that are not typical signs of psychological distress in this context. Feeling more energetic, making future plans, and looking forward to treatment are generally positive indicators of coping and adjustment to the situation.

3. When assessing the respiratory system for complications of immobility, what action should the nurse take?

• A. Inspect chest wall movements primarily during the expiratory cycle.
• B. Auscultate the entire lung region to assess lung sounds.
• C. Focus auscultation on the upper lung fields.
• D. Assess the patient at least every 4 hours.

Correct answer: B

Rationale: The correct action for the nurse when assessing the respiratory system for complications of immobility is to auscultate the entire lung region. This approach allows the nurse to identify any diminished breath sounds, crackles, or wheezes that may indicate respiratory issues. Inspecting chest wall movements primarily during the expiratory cycle (Choice A) may not provide a comprehensive assessment of lung sounds. Focusing auscultation on the upper lung fields (Choice C) may miss important findings in the lower lung fields. Assessing the patient at least every 4 hours (Choice D) is important for monitoring overall patient condition but does not specifically address the assessment of respiratory complications related to immobility.

4. The healthcare provider is teaching a patient about contact lens care. Which instructions will the healthcare provider include in the teaching session?

• A. Use tap water to clean soft lenses.
• B. Wash and rinse the lens storage case daily.
• C. Reuse storage solution for no longer than a week.
• D. Keep the lenses in a cool, dry place when not in use.

Correct answer: B

Rationale: The correct answer is B. Washing and rinsing the lens storage case daily is essential to prevent contamination and infections. Choice A is incorrect as tap water should not be used to clean soft lenses due to the risk of introducing harmful microorganisms. Choice C is incorrect as the storage solution should not be reused for longer than recommended to maintain its effectiveness and prevent eye infections. Choice D is incorrect because lenses should be stored in a clean, disinfected case, not just in a cool, dry place, to avoid contamination.

5. A client requires gastric decompression, and a nurse is inserting an NG tube. Which action should the nurse take to verify proper placement of the tube?

• A. Assess the client for a gag reflex
• B. Measure the pH of the gastric aspirate
• C. Place the end of the NG tube in water to observe for bubbling
• D. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water

Correct answer: B

Rationale: Measuring the pH of the gastric aspirate is the most reliable method to confirm proper placement of an NG tube. Gastric fluid has an acidic pH, typically ranging from 1 to 5. Assessing the client for a gag reflex (choice A) is important for airway protection but does not confirm tube placement. Placing the NG tube in water to observe for bubbling (choice C) is incorrect and not a reliable method for verifying placement. Auscultating 2.5 cm above the umbilicus while injecting sterile water (choice D) is an outdated method and is not recommended for verifying NG tube placement.

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