Nursing Elites

1. Which technique in physical examination is used to assess the movement of air through the tracheobronchial tree?

• A. Palpation
• B. Auscultation
• C. Inspection
• D. Percussion

Correct answer: B

Rationale: The correct answer is B: Auscultation. Auscultation is a technique in physical examination used to assess the movement of air through the tracheobronchial tree. During auscultation, healthcare providers listen to lung sounds using a stethoscope to detect abnormalities such as wheezing, crackles, or diminished breath sounds, which can indicate conditions affecting the airways or lungs. Palpation (Choice A) involves feeling the body for abnormalities, Inspection (Choice C) involves visual examination, and Percussion (Choice D) involves tapping on the body to produce sounds that can help in assessing underlying structures, but they are not directly used to assess air movement through the tracheobronchial tree.

2. A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?

• A. Administer the feeding over 30 minutes
• B. Place the child in a supine position after the feeding
• C. Change the feeding bag and tubing every 3 days
• D. Warm the formula in a warm water bath before administration

Correct answer: B

Rationale: Administering the feeding over 30 minutes helps prevent complications such as aspiration. Placing the child in an upright position after the feeding is recommended to reduce the risk of aspiration. It is essential to change the feeding bag and tubing every 3 days to maintain asepsis and prevent infections. Warming the formula in a warm water bath is the correct method as using a microwave can create hot spots that may burn the child's mouth or throat.

3. 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.

4. A client is being assessed by a nurse who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?

• A. Chest pain
• B. Muscle spasms
• C. Cool, moist skin
• D. Incisional pain

Correct answer: A

Rationale: Chest pain is a critical finding postoperatively, especially after an arterial thrombectomy, as it could indicate complications like myocardial infarction or pulmonary embolism. It requires immediate attention and further evaluation. Muscle spasms, cool moist skin, and incisional pain are important to assess but not as urgent as chest pain in this scenario.

5. Which term is best described as a systematic, rational method of planning and providing nursing care for individuals, families, groups, and communities?

• A. Assessment
• B. Nursing Process
• C. Diagnosis
• D. Implementation

Correct answer: B

Rationale: The correct answer is B: Nursing Process. The nursing process is a systematic, rational method that guides nurses in planning and delivering patient care. It involves a series of steps including assessment, diagnosis, planning, implementation, and evaluation. By utilizing the nursing process, nurses can provide individualized care tailored to the specific needs of patients, families, groups, and communities. Choice A, Assessment, is a step within the nursing process but does not encompass the entire process itself. Choice C, Diagnosis, is another step within the nursing process and focuses on identifying the patient's health problems. Choice D, Implementation, is also a step in the nursing process where the care plan is put into action, but it does not solely describe the entire systematic and rational method of planning and providing nursing care.

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