Nursing Elites

1. When educating a client who experienced a pneumothorax, which of the following statements should the nurse use?

• A. Notify the provider if you experience weakness.
• B. You should be able to return to work in 1 week.
• C. You need to wear a mask when in crowded areas.
• D. Notify your provider if you experience a productive cough.

Correct answer: D

Rationale: After experiencing a pneumothorax, it is crucial for the client to be educated on potential complications. A productive cough can indicate infection or another issue, requiring prompt medical attention. Weakness, returning to work, and wearing a mask in crowded areas are important considerations but not as critical as monitoring for respiratory symptoms post-pneumothorax.

2. What is another name for the knee-chest position?

• A. Genu-dorsal
• B. Genu-pectoral
• C. Lithotomy
• D. Sim’s

Correct answer: B

Rationale: The knee-chest position is correctly identified as the genu-pectoral position. In this position, a person rests on their knees and chest with the abdomen raised and the head turned to one side. This position is commonly used in medical examinations and procedures involving the rectal or pelvic areas, allowing for better visualization and access. Choice A, 'Genu-dorsal,' is incorrect as it does not refer to the knee-chest position. Choice C, 'Lithotomy,' is incorrect as it refers to a position where the patient is lying on their back with legs flexed and feet in stirrups, commonly used during childbirth or certain surgeries. Choice D, 'Sim’s,' is incorrect as it refers to a position where the patient lies on their left side with the right knee and thigh drawn up with the left arm placed along the back.

3. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

• A. Less than 30 ml/hour
• B. 64 ml in 2 hours
• C. 90 ml in 3 hours
• D. 125 ml in 4 hours

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

4. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?

• A. Arrange for an ethics committee meeting to address the family's concerns.
• B. Support the family's decision and initiate life-sustaining measures.
• C. Complete an incident report.
• D. Encourage the family to contact an attorney.

Correct answer: A

Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.

5. 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.

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