Nursing Elites

1. If the child does not have ear problem, using IMCI, what should you as the nurse do?

• A. Check for ear discharge
• B. Check for tender swellings behind the ear
• C. Check for ear pain
• D. Go to the next question, check for malnutrition

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:

• A. Client lying on his back then flat on his abdomen on Trendelenburg position
• B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his
• C. Client lying flat on his back and then flat on his abdomen
• D. Client lying on his right then left side on Trendelenburg position

Correct answer: A

Rationale: Proper patient positioning is essential for maximizing lung expansion and promoting the drainage of secretions. Postural drainage techniques rely on gravity to help clear different lung segments, which is critical in preventing complications such as atelectasis or pneumonia in immobilized patients.

3. Which change during pregnancy is related to the slowing of the gastrointestinal tract?

• A. Diarrhea
• B. Constipation
• C. Decreased absorption of iron
• D. Decreased absorption of calcium

Correct answer: B

Rationale: During pregnancy, the gastrointestinal tract tends to slow down, leading to constipation. This is due to hormonal changes that relax the intestinal muscles, allowing more time for nutrient absorption and ultimately leading to constipation. Diarrhea is not typically associated with the slowing of the gastrointestinal tract during pregnancy. Decreased absorption of iron and calcium may occur during pregnancy due to increased demands, but they are not directly related to the slowing of the gastrointestinal tract.

4. Among people who are ill, significant weight loss may be masked by?

• A. dehydration
• B. a large tumor
• C. drug therapy
• D. fluid retention

Correct answer: D

Rationale: Fluid retention can mask weight loss in ill individuals as the retained fluid adds to body weight, making it difficult to detect true fat or muscle loss. Dehydration (Choice A) would actually lead to weight loss rather than masking it. While a large tumor (Choice B) could contribute to weight loss, it would not mask the weight loss itself. Drug therapy (Choice C) may cause side effects, including weight changes, but it is unlikely to mask significant weight loss in the same way that fluid retention does.

5. A nurse is providing anticipatory guidance to a client who has Phenylketonuria (PKU) and is planning a pregnancy. Which of the following information should the nurse include in the discussion?

• A. Diet sodas should not be consumed more than two or three times a week.
• B. Serum bilirubin should be monitored once or twice a month during pregnancy.
• C. Breastfeeding will not prevent your baby from developing PKU.
• D. A low-protein diet should be followed for three months before conception.

Correct answer: D

Rationale: A low-protein diet should be followed for three months before conception in individuals with PKU who are planning a pregnancy. This diet helps manage PKU by reducing phenylalanine levels, which is crucial for maternal and fetal health. Choices A, B, and C are incorrect. Choice A is not directly related to managing PKU, choice B focuses on a different aspect of care during pregnancy, and choice C is inaccurate as breastfeeding will not prevent a baby from developing PKU.

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