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. Which of the following interventions promotes patient safety?

• A. Assess the patient’s ability to ambulate and transfer from a bed to a chair
• B. Demonstrate the signal system to the patient
• C. Check to see that the patient is wearing their identification band
• D. All of the above

Correct answer: D

Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient’s ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.

3. During an assessment, a healthcare provider observes a client with a chest tube and drainage system. What is an expected finding?

• A. Continuous bubbling in the water seal chamber
• B. Gentle constant bubbling in the suction control chamber
• C. Drainage system positioned upright at chest level
• D. Exposed sutures without dressing

Correct answer: B

Rationale: When assessing a client with a chest tube and drainage system, gentle constant bubbling in the suction control chamber is an expected finding. This indicates that the system is functioning properly. Continuous bubbling in the water seal chamber would suggest an air leak, the drainage system should be positioned upright at chest level to promote proper drainage, and exposed sutures without dressing would be an incorrect finding as they should be covered to prevent infection.

4. A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

• A. Apply a vest restraint if self-extubation is attempted.
• B. Monitor ventilator settings every 8 hours.
• C. Document tube placement in centimeters at the angle of the jaw.
• D. Assess breath sounds every 1 to 2 hours.

Correct answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

5. Which action would break sterile technique while preparing a sterile field for a dressing change?

• A. Using sterile forceps instead of sterile gloves to handle a sterile item
• B. Touching the outside wrapper of sterilized material without sterile gloves
• C. Placing a sterile object at the edge of the sterile field
• D. Pouring out a small amount of solution (15 to 30 ml) before pouring it into a sterile container

Correct answer: B

Rationale: Touching the outside wrapper of sterilized material without sterile gloves can introduce contaminants and compromise the sterility of the item. It is crucial to maintain strict adherence to sterile technique to prevent infections and ensure patient safety during procedures.

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