Nursing Elites

1. A client has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?

• A. Teach the client to scan the right to see objects on the right side of their body.
• B. Place the bedside table on the right side of the bed.
• C. Orient the client to the food on their plate using the clock method.
• D. Place the wheelchair on the client's left side.

Correct answer: B

Rationale: In a client with left homonymous hemianopsia, there is a loss of vision on the right side of both eyes. Placing the bedside table on the right side of the bed ensures that essential items are within the client's field of vision, minimizing the risk of injury or accidents. Teaching the client to scan to the right and orienting them using the clock method may be helpful strategies, but placing the bedside table on the right side of the bed is a more direct and immediate intervention to enhance the client's safety and independence.

2. When caring for a client on pressure support ventilation (PSV), which statement by the nurse indicates an understanding of PSV?

• A. It keeps the alveoli open and prevents atelectasis.
• B. It allows preset pressure delivered during spontaneous ventilation.
• C. It guarantees minimal minute ventilator.
• D. It delivers a preset ventilatory rate and tidal volume to the client.

Correct answer: B

Rationale: Pressure support ventilation (PSV) is a mode that delivers a preset pressure when the client initiates a breath. This support helps the client to breathe spontaneously by reducing the work of breathing. The correct statement indicating an understanding of PSV is that it allows preset pressure to be delivered during spontaneous ventilation, as it assists the client's efforts without controlling the rate or volume of each breath.

3. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?

• A. Use a professional interpreter service
• B. Nurse to interpret
• C. Provide translation services for a nominal fee to clients
• D. Evaluate the clients' understanding at regular intervals

Correct answer: B

Rationale: In situations where there is a language barrier between healthcare providers and patients, it is essential to ensure accurate communication. Using professional interpreter services is the most appropriate choice to ensure clear and precise communication. Relying on the client's children for interpretation may not guarantee accurate or confidential communication. Asking the nurse to interpret can lead to miscommunication or misunderstanding of important medical information. Providing translation services for a nominal fee to clients may not always be feasible or culturally appropriate. Regularly evaluating the client's understanding helps ensure that information is effectively communicated and comprehended.

4. How many milliliters are equal to 20 cc?

• A. 2
• B. 20
• C. 2000
• D. 20000

Correct answer: B

Rationale: 1 cc (cubic centimeter) is equal to 1 ml. Therefore, 20 cc is equal to 20 ml. To convert between cubic centimeters (cc) and milliliters (ml), the values are equivalent since they both measure volume in the metric system. Choice A (2) is incorrect as it does not account for the direct conversion between cc and ml. Choice C (2000) and choice D (20000) are incorrect as they represent conversions based on a misunderstanding of the relationship between cc and ml.

5. In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?

• A. Obtain a chest X-ray.
• B. Prepare for chest tube insertion.
• C. Administer oxygen via high-flow mask.
• D. Initiate IV access.

Correct answer: C

Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.

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