Nursing Elites

1. In assessing the client's chest, which position best shows chest expansion as well as its movements?

• A. Sitting
• B. Prone
• C. Sidelying
• D. Supine

Correct answer: A

Rationale: The correct answer is A: Sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B, Prone, is incorrect as lying face down would not provide a clear view of chest expansion. Choice C, Sidelying, is also incorrect as this position may limit the visibility of chest movements. Choice D, Supine, is not the best position for assessing chest expansion as it may not offer a clear observation of chest movements during breathing.

2. Which hospital level is a 296-bed facility that is staffed and equipped to provide care for all categories of patients?

• A. FSB
• B. CSH
• C. GH
• D. FH

Correct answer: C

Rationale: The correct answer is "GH" (General Hospital), which is a 296-bed facility providing comprehensive care for all categories of patients. Choice A, FSB, is incorrect as it does not denote a hospital level. Choice B, CSH, is incorrect as it does not specify a 296-bed facility. Choice D, FH, is incorrect as it does not indicate a hospital level or capacity.

3. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

• A. The client with an abdominal aortic aneurysm who is constipated
• B. The client on bed rest who ambulated to the bathroom
• C. The client with essential hypertension who has epistaxis and a headache
• D. The client with arterial occlusive disease who has a decreased pedal pulse

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis, requiring immediate intervention. Option A is incorrect as constipation in a client with an abdominal aortic aneurysm, though important, does not indicate an immediate need for assessment. Option B, a client on bed rest who ambulated to the bathroom, does not present with urgent signs or symptoms requiring immediate assessment. Option D, a client with arterial occlusive disease and a decreased pedal pulse, needs attention but is not the priority compared to a hypertensive crisis with epistaxis and headache.

4. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

• A. Building rapport with the child
• B. Taking the child’s temperature
• C. A, D
• D. Obtaining an interpreter if necessary

Correct answer: C

Rationale: Building rapport with the child is essential to establish trust and cooperation during the assessment. Admiring the child may not be appropriate in a professional setting and might not contribute significantly to the assessment. Taking the child's temperature is a routine part of the assessment but may not be the most critical action in this scenario. Obtaining an interpreter is crucial to ensure effective communication between the healthcare team and the child and their mother, especially considering potential language barriers.

5. The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion?

• A. Start the transfusion at 10-15 mL per hour for 15-30 minutes
• B. Re-crossmatch the blood until the antibodies are identified
• C. Have the client sign a permit to receive uncrossmatched blood
• D. Have the unlicensed nursing assistant stay with the client

Correct answer: A

Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is essential when the cross-match reveals the presence of antibodies that cannot be cross-matched. This precaution allows the nurse to monitor for any adverse reactions due to the antibodies. Re-crossmatching the blood until the antibodies are identified (choice B) may delay the transfusion process and put the client at risk. Having the client sign a permit to receive uncrossmatched blood (choice C) is not a standard practice and does not address the immediate need for precautions during transfusion. Having the unlicensed nursing assistant stay with the client (choice D) is unrelated to the safe initiation of the transfusion and is not a precaution specific to managing antibodies in blood products.

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