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. What is the best description of Back Care?

• A. Caring for the back by means of massage
• B. Washing the back
• C. Applying a cold compress to the back
• D. Applying a hot compress to the back

Correct answer: A

Rationale: The correct answer is A: Caring for the back by means of massage. Back Care involves activities like massage, exercises, maintaining proper posture, and using ergonomic practices to keep the spine healthy and prevent injuries. While washing the back is a hygiene practice, applying cold or hot compresses may provide relief for back pain but do not encompass the comprehensive approach of back care like massage does.

3. Which of the following patients is at greatest risk for developing pressure ulcers?

• A. An alert chronic arthritic patient treated with steroids and aspirin
• B. An 88-year-old incontinent patient with gastric cancer who is confined to bed at home
• C. An apathetic 63-year-old COPD patient receiving nasal oxygen via cannula
• D. A confused 78-year-old patient with congestive heart failure (CHF) who requires assistance to get out of bed

Correct answer: B

Rationale: The correct answer is B. An elderly patient who is incontinent, bedridden, and suffering from a serious illness like gastric cancer is at the highest risk for developing pressure ulcers. Being bedridden and incontinent increases the pressure on certain areas of the body, leading to tissue damage and the development of pressure ulcers. Additionally, the patient's age and underlying health condition further contribute to their risk. It is crucial to identify and address such risk factors promptly to prevent the occurrence of pressure ulcers in vulnerable patients.

4. What is the primary purpose of handwashing?

• A. To promote hand circulation
• B. To prevent the transfer of microorganisms
• C. To avoid touching the client with a dirty hand
• D. To provide comfort

Correct answer: B

Rationale: The primary purpose of handwashing is to prevent the transfer of microorganisms. Proper hand hygiene helps reduce the risk of spreading harmful bacteria and viruses, thus promoting overall health and preventing infections. Choice A is incorrect as handwashing primarily focuses on cleanliness rather than promoting circulation. Choice C is incorrect as it implies that the main concern is avoiding client discomfort rather than preventing infection. Choice D is incorrect as while handwashing can be comforting in some situations, its primary purpose is not to provide comfort but to maintain hygiene.

5. 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.

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