Nursing Elites

1. A client is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?

• A. Supine with head elevated
• B. Lateral recumbent
• C. Prone with arms at sides
• D. Sitting with back rounded

Correct answer: B

Rationale: The correct position for a lumbar puncture is the lateral recumbent position. This position allows the spine to curve naturally, widening the spaces between the vertebrae, making it easier and safer to perform the procedure. Supine with head elevated (Choice A) would not provide the proper positioning for a lumbar puncture as it does not allow for proper access to the lumbar area. Prone with arms at sides (Choice C) would not be suitable as it would not facilitate the procedure. Sitting with back rounded (Choice D) is also incorrect as it does not allow for the proper alignment of the spine needed for a lumbar puncture.

2. What is the best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care?

• A. Instruct the client to rest completely and avoid all self-care tasks
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to complete all self-care tasks
• D. Ask the client's family to assist with self-care tasks

Correct answer: B

Rationale: The best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care is to encourage the client to gradually resume self-care tasks with frequent rest periods. This approach helps the client regain independence while managing fatigue effectively. Choice A is incorrect because complete rest without any self-care tasks may hinder recovery and independence. Choice C is not the best option as it does not promote the client's independence. Choice D, while involving family support, does not empower the client to regain self-care abilities.

3. Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?

• A. Insert the suction catheter while the client is swallowing
• B. Apply intermittent suction when withdrawing the catheter
• C. Place the catheter in a clean, dry location for later use
• D. Hold the suction catheter with the non-dominant hand

Correct answer: B

Rationale: The correct technique when performing nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps reduce trauma to the mucosa by preventing prolonged suctioning. Choice A is incorrect because inserting the suction catheter while the client is swallowing may increase the risk of aspiration. Choice C is incorrect as placing the catheter in a clean, dry location for later use is not a safe practice as it can lead to contamination. Choice D is incorrect since it does not address the proper technique involved in nasotracheal suctioning.

4. What are the key nursing interventions for a patient undergoing dialysis?

• A. Monitor fluid balance and administer heparin
• B. Monitor blood pressure and prevent clot formation
• C. Administer medications and monitor blood chemistry
• D. Provide dietary education and encourage protein intake

Correct answer: A

Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.

5. A client with a tracheostomy is experiencing increased secretions and labored breathing. What should the nurse do first?

• A. Administer a bronchodilator
• B. Suction the tracheostomy
• C. Encourage the client to cough
• D. Notify the provider

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy first. When a client with a tracheostomy is experiencing increased secretions and labored breathing, suctioning the tracheostomy is the priority intervention to clear the airway and improve breathing. Administering a bronchodilator (Choice A) may help with breathing but should come after ensuring the airway is clear. Encouraging the client to cough (Choice C) may not be effective in clearing secretions from the tracheostomy. Notifying the provider (Choice D) can be done after ensuring immediate airway clearance.

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